Fill and Sign the Undersigned Being First Duly Sworn Says that the Plaintiff Has Filed the above Captioned Action to Recover Possession Form

□ Deputy CSC □ Assistant CSC □ Clerk Of Superior Court The undersigned, being first duly sworn , says t hat the plaintiff has f iled the above-capt ioned action to r ecover possession o f personal pr operty and now before j udgment in the pr incipal act ion claims t he immediate delivery of the personal pr operty described as f ollows until final j udgment: T he plainti ff owns t he property, or is lawf ully entit led to its possession by vi rtue of a special pr operty interest ther ein, descr ibed as f ollows: (set forth special interest in property) The pr operty is wr ongfully detained by t he defendant, and the cause o f det ention, accor ding to affiant's knowledge, information and belief, is as follows: T he pr operty has not been t aken for t ax , ass essment or fine, pursuant to a statute , or seized under an execution or attachment against the property, or if so seized, it is, by statute , exemp t from such seizure. T he act ual value o f the property is listed below. T he undersigned r equests the Clerk o f S uper ior Court to issue a Notice of Hear ing in this ma tter, and f urther requests t hat an or der be enter ed enjoining t he defendant from willfully disposing o f the property in any manner, from removing o r permi tting the removal o f the property from t he State of North Carolina, or from causing o r permi tting willful destruct ion of t he pr operty. STATE OF NORTH CAROLINA File No. Date My Commiss ion Expires County G.S. 1-473; 475 AOC- CV-200, Rev. 3/14 © 2014 Administrative Office of the Courts F ilm No. Signature Of Affiant SWO RN/A FFIRMED AND SUBSCRIBED T O BEFORE ME $ Date Signature Of Person Authorized to Administer Oaths SEAL Name Of Plaintiff Name Of Defendant Actual Value Of The Property Name Of Affiant (Type Or Print) County Where Notarized A FFIDAVIT AND REQUEST FOR HEARING IN CLAIM AND DELIVERY VERSUS □ Plaintiff □ Attorney □ Agent In The G eneral Cour t Of Justice □ District □ Super ior Cour t Division □ Notary