Fill and Sign the In the County Named above You Unlawfully and Willfully Did Make a False Statement and Representation Knowing Form

Name And Address Of Employer From Whom Actual Earnings Earned ORIGINAL Date Of Arrest & Check Digit No. (As Shown On Fingerprint Card) File No. ORIGINAL CRIMINAL SUMMONS EMPLOYMENT SECURITY LAW STATE OF NORTH CAROLINA In The General Court Of Justice District Court Division County To the defendant: I, the undersigned, find that there is probable cause t o believe that on or about the date of offense shown a nd in the county named above you unlawfully and willfully di d make a false statement and representation knowing it to be false, and did knowingly fail to disclose a mate rial fact, in that you reported to a representative of the Employment Security Commission of North Carolina the "Re ported Earnings" shown below for the seven day reporting period which ended on the "Ending Date" sho wn below when you in fact earned the "Actual Earnings" shown below from the employer named below. Your false statement and representation and failure to disclose a material fact were to obtain and increase a benefit under the Employment Security Law. This act was in violation of the law referred to in this Criminal Summons. This Summons is issued upon information furnished under oath by the complainant li sted. You are ORDERED to appear before the Court at the location, date and time indicated below to answer to the charge. If you fail to appear, an order for your arrest may be issued and you may be held in CONTEMPT OF C OURT and imprisoned for up to thirty (30) days or fined up to $500.00 or both. This penalty for failure to appear is in addition to any sentence which may be imposed for the crime charged. Signature AM PM Offense Code(s) THE STATE OF NORTH CAROLINA VS. Magistrate Assistant CSC Deputy CSC Clerk Of Superior Court Offense In Violation Of G.S. 2663 96.18(a) AOC-CR-916M, Rev. 8/97 (Structured Sentencing) Misdemeanor Offense Which Requires Fingerprinting Per Fingerprint Plan Ending Date Reported Earnings $ Actual Earnings $ Name And Address Of Defendant County Of Residence Telephone No. Drivers License No. & State Name Of Defendant's Current Employer Complainant (Name, Address Or Department) County Of Residence Names & Addresses Of Witnesses (Including Counties & Telephone Nos.) Location Of Court Social Security No. Race Sex Date Of Birth Age Date Of Offense Telephone No. Date Issued 1997 Administrative Office of the Courts Court Date Court Time Signature Signature Of District Court Judge Signature Signature Of District Court Judge No./Level: Signature Of Officer Making Return Dep. CSC Asst. CSC CSC JUDGMENT: The defendant appeared in open court and freely, voluntarily and understandingly entered the above plea; on the above verdict it is ORDERED that the defendant: PRIOR CONVICTIONS: The defendant, in open court, gives notice of appeal to the Superior Court. The current pretrial release order is modified as follows: guilty guilty not guilty MISD. CLASS: MISD. CLASS: This Criminal Summons WAS NOT served for the following reason: pay costs and a fine of $ . CSC If this Criminal Summons is not served within ninety (90) days, it must be returned to the Clerk of Court in the county in which it was issued with the reason for the failure of service noted thereon. The officer must state all steps taken by the department in attempting to serve the Summons and any information obtained about the whereabouts of the defendant. RETURN OF SERVICE I certify that this Criminal Summons was received and served as follows: Date Served By personally serving this Criminal Summons on the defendant. Appointed Retained Waived no contest no contest PLEA: VERDICT: guilty guilty not guilty Deputy CSC Assist. CSC be imprisoned for a term of days in the custody of the sheriff. DOC. Pretrial Credit days served. Work release is recommended. is not recommended. [ is ordered. (use form AOC-CR-602) ] The Court finds that a longer shorter period of probation, than that which is specified in G.S. 15A-1343.2(d), is necessary. With defendant's consent, execution of the sentence is suspended and the defendant is placed on unsupervised probation for months, subject to the following conditions: (1) commit no criminal offense in any jurisdiction. (2) possess no firearm, explosive or other deadly weapon listed in G.S. 14-269. (3) remain gainfully and suitably employed or faithfully pursue a course of study or of vocational training, that will equip the defendant for suitable employment, and abide by all rules of the insti tution. (4) satisfy child support and family obligations, as required by the Court. (5) pay to the Clerk the costs of court and any additi onal sums shown below. . . I certify that this Judgment is a true and complete copy of the original which is on file in this case. CERTIFICATION 6. complete hours of community service during the first days of probation, as directed by the community service coordinator, and pay the fee prescribed by G.S. 143B-475.1(b) within days. 7. not be found in or on the premises of the complainant or . 8. not assault, communicate with or be in the presence of the complainant or . 9. Other: This Criminal Summons WAS NOT served for the following reason: 2 3 2 3 COMMITMENT: It is ORDERE D that the Clerk deliver two certified copies of this Judgment and Commitment to the sheriff and that the sheriff cause the defendant to be retained in custody to serve the sentence imposed or until the defendant shall have com plied with the conditions of release pending appeal. It is ORDERED that this: Judgment is continued upon payment of costs. case be consolidated for judgment with sentence is to run at the expiration of the sentence in 0 I (0) II (1-4) III (5+) A PPEA L ENTRIES REISSUANCE Signature Of Officer Making Return RETURN FOLLOWING REDELIVERY I certify that this Criminal Summons was received and served as follows: By personally serving this Criminal Summons on the defendant. 11 AOC-CR-916M, Side Two, Rev. 8/97 (Structured Sentencing) NOTE: If DWI, use AOC-CR-301 (active) or AOC-CR-310 (probation). If active sentence to DOC, u se AOC-CR-602. If supervised probation, use AOC-CR-604. Department Or Agency Of Officer Department Or Agency Of Officer District Attorney Attorney For Defendant At Time Of Trial Or Plea Name Of District Court Judge (Type Or Print) Date Date Date Delivered To Sheriff Date Date Received Date Returned Date Received Date Served Date Returned Date 1997 Administrative Office of the Courts $ $ $ $ $ *Name(s), address(es), amount(s) & social security number(s) of aggrieved p arty(ies) to receive restitution: Fine Restitution* Attorney's Fee Community Service Fee Other