Fill and Sign the State of North Carolina North Carolina Real Estate Form

County Where Notarized AOC-SP-260, New 2/06 © 2006 Administrative Office of the Courts Notary SEAL Deputy CSC Date SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME STATE OF NORTH CAROLINA File No. I am a licensed real estate broker in North Carolina; I received the funds listed below as disputed funds in a fiduciary capacity; The disputed funds relate to real property in this county; The disputed funds are not a residential security d eposit; I notified the persons who are claiming ownership i n the money of my intent to deposit the funds with the Clerk of Court and of their right to initiate a spe cial proceeding to recover the disputed funds, and I sent the notice to the persons claiming the dispu ted funds at least 90 days prior to filing this "Certificate of Notice and Deposit of Disputed Funds" by hand -delivering mailing by first class mail at the addresses listed below, which are the last addresses known to me. Name And Address Of Person 1 Name And Address Of Person 3 Name And Address Of Person 5 Name And Address Of Person 7 Name And Address Of Person 2 IN THE MATTER OF: Name Of Real Estate Broker Depositing Funds Broker License Number CERTIFICATE OF NOTICE AND DEPOSIT OF DISPUTED FUNDS G.S. 93A-12 I, the undersigned, certify that Amount Of Disputed Funds $ Name And Address Of Person 4 Signature Of Person Authorized To Administer Oaths Clerk Of Superior Court Date My Commission Expires Assistant CSC Name Of Real Estate Broker (Type Or Print) Signature Of Real Estate Broker Date Name And Address Of Person 6 Name And Address Of Person 8 In The General Court Of Justice Superior Court DivisionBefore The Clerk County