Fill and Sign the Officers Affidavit for Seizure and Form

I. OFFICER’S AFFIDAVIT File No. OFFICER’S AFFIDAVIT FOR SEIZURE AND IMPOUNDMENT AND MAGISTRATE’S ORDER - IMPAIRED DRIVING G.S. 20-28.3 Name And Address Of Defendant Vehicle Identification No. Name And Address Of Vehicle Owner Present Location Of Motor Vehicle Defendant’s Drivers License No. State State Year Make ModelBody Style (TYPE OR PRINT IN BLACK INK) STATE OF NORTH CAROLINA County In The General Court Of Justice District Court Division Date Of Offense Date Of Seizure Time Of Seizure The undersigned being first duly sworn says: 1. I am a law enforcement officer. On or about the date of offense shown ab\ ove, I had probable cause to believe that the defendant named above drov\ e the motor vehicle described above in the above county upon (Give street, highway or public vehicular area.) while committing an offense involving impaired driving in violation of G.S. 20-138.1 G.S. 20-138.5 G.S. (See Section III on reverse for a list of offenses involving impaired driving.) in that: (List sufficient facts to constitute probable cause.) . (Check if defendant charged under G.S. 20-138.5.) and a check of the Division of Motor Vehicles’ records or other reli\ able information indicates that the defendant has been convicted of three (3) or more offenses involving impaired drivin\ g as defined in G.S. 20-4.01(24a) within ten (10) years of the date \ of offense shown above. 2. I charged the defendant with an offense in violation of the statute c\ ited above. 3. A check of the records of the Division of Motor Vehicles or other reliab\ le information indicates that, at the time of the above offense, the defendant’s drivers license was revoked as a result of a prior i\ mpaired driving license revocation as defined in G.S. 20-28.2(a). (See Section IV on reverse for a list of impaired driving license revocations.) the defendant was driving without a valid drivers license and was not c\ overed by an automobile liability insurance policy. 4. A check of law enforcement records or other reliable information indi\ cates that the motor vehicle described above has not been reported stole\ n. 5. The motor vehicle described above is not a rental vehicle, or if it i\ s a rental vehicle, the defendant is listed as an authorized driver on t\ he rental contract. 6. (a) On the date of seizure shown above, I seized the vehicle describe\ d above and it is presently at the location shown above. (b) The motor vehicle has not yet been seized. On the basis of the facts set forth in the above Affidavit and any addit\ ional information furnished under oath, the undersigned finds that the r\ equirements of G.S. 20-28.3 for the seizure and impoundment of the motor vehicle described above have have not been met. 1. a. It is ORDERED that the above described motor vehicle be impounded an\ d held pending further orders of the court. b. It is ORDERED that any officer with authority and jurisdiction seize the\ above described motor vehicle and that it be impounded and held pending\ further orders of the court. 2. It is ORDERED that the above described motor vehicle be released to the \ motor vehicle owner upon payment of all towing and storage charges incur\ red as a result of the seizure of that vehicle. NOTE TO OFFICER: The seizing officer shall notify the Division of Motor Vehicles (DMV) \ of the seizure as soon as practical, but not later than 24 hours after t\ he seizure of the motor vehicle. G.S. 20-28.3(b). The seizing officer should comp\ lete form LT-176 and forward it to the officer’s DCI terminal operato\ r. The terminal operator will then transmit the information to DMV via DCI. Thi\ s Order authorizes any officer with jurisdiction to enter the property o\ f the defendant to seize the motor vehicle. Consent or a search warrant is req\ uired to enter the private property of another. G.S. 20-28.3(c1). NOTE TO MAGISTRATE: The magistrate shall provide the original of this form to the Clerk. G.S\ . 20-28.3(c). The magistrate should provide copies to the defendant an\ d to the seizing officer. NOTE TO CLERK: If a seizure is ordered, the Clerk shall provide copies of this form to \ the district attorney and the attorney for the county board of education\ . G.S. 20-28.3(c). II. MAGISTRATE’S ORDER Vehicle License No. AM PM SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME Date Date Name Of Magistrate (type or print) Signature Of Magistrate Signature Of Official Authorized To Administer Oaths Signature Of Seizing Officer Name Of Seizing Officer (type or print) Name Of Department Or Agency Of Officer Deputy CSC Assistant CSC Clerk Of Superior Court Magistrate Date My Commission Expires County Where Notarized Notary SEAL (Over) AOC-CR-323A, Rev. 3/17