North Carolina Governor Cooper Letter Request Form

State of North Carolina

APPLICATION FOR REQUISITION
(AFTER CONVICTION)

TO THE GOVERNOR OF THE STATE OF NORTH CAROLINA, : THE

UNDERSIGNED Department of Correction Official District Attorney Assistant District Attorney

hereby makes this verified application for the requisition of

the accused, charged in the County of

with the (crime of escape or violation of terms of parole, conditional release, probation, bail)

and who is now in the jurisdiction of the State of

as defined in North Carolina General Statutes

IN SUPPORT OF SUCH APPLICATION, YOUR PETITIONER HEREBY SHOWS THE FOLLOWING FACTS:

1. That the FULL NAME of the person for whom requisition is asked is

2. That in his/her opinion, the ends of public justice require that the subject be arrested and brought back to the State of North Carolina at state or county expense in accordance with N. C. General Statutes 15A-744 et seq.

3. That he/she believes that he/she has sufficient evidence to secure (a) the conviction of the subject; OR (b) to prove that said subject has violated the conditions of

4. That the name of the AGENT - proposed to receive the subject from the proper authorities of the State of

and bring said subject to the State of North Carolina for (a) trial (b) hearing is (are)

and/or Authorized Agent(s);

AND that the person - named as AGENT - is (are) a proper person - and that he/she (they) has (have) no private interest in the arrest and disposition of said fugitive.

5a. That, according to information and belief, there HAS NOT BEEN a former request for the requisition of the subject, growing out of the same transaction herein alleged.

5b. That, there HAS BEEN a former request for the requisition of the subject, growing out of the same transaction herein alleged: (date of prior application)

(explanation of reasons for present request for requisition)

APPLICATION FOR REQUISITION
(AFTER CONVICTION)

6. That the subject is now under ARREST in the State of , and in the custody of

and the grounds for such belief is as follows:

(and has been released on bail from this custody, and is presently residing at ).

7. That this Application is not made for the purpose of serving the accused with civil process, or for the purpose of collecting a debt or enforcing a private claim, or for any private purpose whatever, and that if the requisition applied for be granted, the criminal proceedings, or hearing, will not be used for any of said objects.

8. That the extradition of the subject to the State of North Carolina is hereby requested for the purpose of (a) TRIAL or (b) HEARING on the charge of (a) (escape)

OR for violation of the conditions of (b) (parole, conditional release, probation, bail)

as defined in North Carolina General Statutes , and as set forth in, and attached hereto:

a. Warrant and Affidavit for Escape (District Attorney or Assistant District Attorney), dated ; OR

Certified Statement of Officer from whose custody accused escaped (Department of Correction), dated

b. Probation Judgment imposed and dated ;

c. Conditional Release imposed and dated ;

d. Certificate of Parole dated ;

e. Allowance of Bail dated ;

[details (escape date; revocation date)]

AFTER HAVING BEEN CONVICTED OF THE FOLLOWING CRIME (Show name of crime; N.C.G.S. citation; date; place; judgment; sentence):

APPLICATION FOR REQUISITION
(AFTER CONVICTION)

9a. That said subject was personally and physically present in North Carolina, at the time of the commission of the alleged crime or violation; and thereafter, the subject fled from the State of North Carolina to avoid arrest and prosecution.

9b. That said subject, insofar as is known, WAS NOT IN THE STATE OF NORTH CAROLINA at the time of the alleged VIOLATION, and has not since that time fled from this State, but that this Requisition is sought under Section 6 of the Uniform Extradition Act,

G.S. 15A-726, which your Applicant is informed has been adopted by the State of ; and

that the subject, while in the State of , committed an Act, to wit:

which intentionally resulted in the violation of , in the State of North Carolina.

10a. That this Application was made as soon as the subject could be located.

10b. That there has been a considerable lapse of time since the date of the alleged crime or charge, explanation of which is as follows:

11. That this Application is verified, as aforesaid; is executed; and is accompanied by the following certified documents:

(a) Warrant and Affidavit or Indictment, Organization of Court, Judgment upon Conviction and Sentence upon which subject was being held at time of escape or violation of conditions of bail. In addition, District Attorney or Assistant District Attorney: Warrant and Affidavit for Escape; Department of Correction: Statement of Officer from whose custody accused escaped, and other records, if available, certified to by the Division of Prisons of the Department of Correction. (Fingerprint, FBI Transcript) - Escapees; Bail Violators.

(b) Warrant and Affidavit or Indictment, Organization of Court, Judgment upon Conviction and Sentence; (certified to by Clerk of Court). (And other records, certified to by the Division of Prisons of the Department of Correction, such as: Fingerprints, FBI Transcript; and Other Records, certified to by the Parole Commission, such as: (a) Certificate of Parole and Revocation of Parole; (b) Certificate of Conditional Release and Revocation of Conditional Release.) - Violators of Parole and Conditional Release.

(c) Warrant and Affidavit or Indictment, Organization of Court; Probation Judgment; Probation Violation Report and Order for Arrest. - Violators of Probation.

APPLICATION FOR REQUISITION
(AFTER CONVICTION)

12. , being duly sworn, deposes and says:

I am . I have read the foregoing application for the return of the named accused to the State of North Carolina, and the facts therein stated are true according to the best of my knowledge, information, and belief.

SEAL

Sworn and subscribed to before me, this the day of ,

(1) This Application may be used for: Escapees from the Division of Prisons of the Department of Correction, G.S. 148-45; Escapees, County and Municipal, G.S. 14-256; Violators of conditions of: Probation, G.S. 15A-1343; Parole, G.S. 15A-1374; or violation of conditions of bail, all of which have been committed after conviction or confinement.

(2) Select the appropriate subsection which applies in Sections 3, 4, 5, 8, 9, 10, and 11.

(3) Attach Copy of applicable Statute for Escape or Violation.

(4) Attach identification: Fingerprints and/or photograph.