Congress of the United States

House of Representatives

Washington, D.C. _____-____

 

constituent assistance form

Privacy Act of 1974 (Public Law 93-579)

The Federal Privacy Act prohibits the disclosure of confidential information concerning your written

authorization. If you wish for _______’s office to make an inquiry on your behalf, print this authorization

form, fill in the necessary information and send it to the office nearest you.

 

 

            The 1st District Office                             The 2nd District Office                          The 3rd District Office

                U.S. Representative Blank                      U.S. Representative Blank                      U.S. Representative Blank                     

                500 Johnson Road                                  500 Johnson Road                                  500 Johnson Road

                Mayberry, N.C. 27777                           Mayberry, N.C. 27777                           Mayberry, N.C. 27777

                Phone: (000) 777-9311                           Phone: (000) 777-9311                           Phone: (000) 777-9311

                Fax: (000) 777-9312                               Fax: (000) 777-9312                               Fax: (000) 777-9312

               

               

               

               

 

 

               

               

               

               

           

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATE OF NORTH CAROLINA                           IN THE GENERAL COURT OF JUSTICE

                                                                                          DISTRICT COURT DIVISION

COUNTY OF DURHAM                                                                      -CVD-

 

 

 

______________________________    )                 

      (type or print your spouse’s name here)          )

                                                                )

                                    Plaintiff,             )

                                                                )                              DEFENDANT’S ACCEPTANCE                        

                                                                )                                    OF SERVICE OF PROCESS

      vs.                                                      )                               AND GENERAL APPEARANCE

                                                                )

                                                                )

                                                                )                              

______________________________    )                      

            (type or print your name here)                  )

                                                                                )      

                                     Defendant.             )

                                                                )

                                                             

 

 

             I, _______________________________, defendant named in the above-entitled civil action, do hereby accept service of the summons and complaint in this action and hereby admit the service of summons and complaint has been made upon me in the above-entitled action; I hereby admit and acknowledge that a copy of the summons and complaint in the above-entitled action was personally delivered to and received by me; I hereby waive further service of the summons and complaint upon me by the Sheriff or other lawful process officer in accordance with the provisions of G.S. 1A-1, Rule 4 (j) of the North Carolina Rules of Civil Procedure; and I hereby make a general appearance in the above-entitled action and expressly submit myself to the personal jurisdiction of the General Court of Justice, District Court Division of Bladen County, North Carolina, for any and all purposes of this action.

 

 

 

 

 

                                                                     ___________________________________________

                                                                     (Sign your name in the Presence of a Notary Public)

 

 

 

 

 

 

STATE OF NORTH CAROLINA      )                        

                                                            )                              VERIFICATION                                                       

COUNTY OF BLADEN                     )                                                                    

 

 

 

 

I, _____________________________, being first duly sworn, depose and says that he/she is the

                      (insert your name here)

 Defendant in this matter, that he/she has read and understood this ANSWER and knows the

 

contents to be true of his/her own personal knowledge, except for those matters and things set

 

forth upon information and belief, and as to those matters and things, he/she believes them to be

 

true.

 

 

                                                                                  ____________________________________

                                                                                     (Sign in the Presence of a Notary Public)

 

 

 

Sworn and subscribed before me this ________ day of ________________________, ________.

 

 

 

 

                                                                                   ____________________________________

                                                                                                           (Notary Public)

 

 

My commission expires: ___________________________________.

 

STATE OF NORTH CAROLINA                                                          ►File No______________________

 

In The General Court Of Justice

  District           Superior Court Division

______________________County

 

STATE VERSUS

REQUESTS AND REPORTS

CONVICTIONS/EXPUNCTIONS

DISMISSALS AND DISCHARE

 

Name And Address Of Defendant (Type or Print)

 

Race

Sex

DOB

S.S.#

Offense To Be Expunged or Dismissed

G.S. No.

 

Relief Requested And Statute Under Which Application Made (Check Only One)

 

  Expunction of records under:       15A-145           15A-146          90-96(b)          90-96(d)          90-96(e)

                                  90-113.14(b)    90-113.14(d)    90-113.14(e)

 

  Dismissal of charges and discharge of defendant under:       90-96(a)       90-113.14(a)

 

 

OFFENSE INFORMATION

 

 

DATE

 

   (Check And Give Date For All Which Apply)

 

  Date Offense Committed

 

 

  Date Of Arrest, Indictment Or Service Of Other Initiating Process

 

 

  Date Of Dismissal Or Finding Of Not Guilty

 

 

  Date Of Guilty Plea Or Date Found Guilty

 

 

  Date Of Dismissal And Discharge Under G.S. 90-96(a) or G.S. 90-113.14(a)

 

 

  Date Of Conviction

 

 

Name And Address Of  Arresting Agency

Name And Address Of Defendant’s Attorney

 

 

 OFFENSE INFORMATION

 

 

I certify that an application under the statute identified above and all affidavits required under that statute have

been filed in this case, that I have served copies on the district attorney, and that the information set forth above

Is a complete and accurate statement of the information on file in the office of the Clerk of Superior Court.

 

Date

Signature

  Defendant                    

 

To The State Bureau Of Investigation, P.O. Box 29500, Raleigh, N.C. 27626

 

Please prepare, certify on the reverse side, and attach to this Request any Criminal Record History Information for

the petitioner. Then forward this request with Criminal Record History Information attached, confidentially to:

Records Officer, Administrative Office of the Courts, Courier Box 56-10-50, Raleigh, N.C. OR if courier is not

Available, mail to: P. O. Box 2448, Raleigh, N.C. 27602.

 

Date

Name Of Presiding Judge (Type Or Print)

Signature Of Presiding Judge

 

 

 

STATE OF NORTH CAROLINA                                                          ►File No______________________

 

In The General Court Of Justice

  District           Superior Court Division

______________________County

STATE VERSUS

REQUESTS AND REPORTS

CONVICTIONS/EXPUNCTIONS

DISMISSALS AND DISCHARE

Name And Address Of Defendant (Type or Print)

Race

Sex

DOB

S.S.#

Offense To Be Expunged or Dismissed

G.S. No.

Relief Requested And Statute Under Which Application Made (Check Only One)

 

  Expunction of records under:       15A-145           15A-146          90-96(b)          90-96(d)          90-96(e)

                                  90-113.14(b)    90-113.14(d)    90-113.14(e)

 

  Dismissal of charges and discharge of defendant under:       90-96(a)       90-113.14(a)

 

OFFENSE INFORMATION

 

 

DATE

 

   (Check And Give Date For All Which Apply)

 

  Date Offense Committed

 

  Date Of Arrest, Indictment Or Service Of Other Initiating Process

 

  Date Of Dismissal Or Finding Of Not Guilty

 

  Date Of Guilty Plea Or Date Found Guilty

 

  Date Of Dismissal And Discharge Under G.S. 90-96(a) or G.S. 90-113.14(a)

 

  Date Of Conviction

 

Name And Address Of  Arresting Agency

Name And Address Of Defendant’s Attorney

 

OFFENSE INFORMATION

 

 

 

 

 

 

 

 

Date

Name of Presiding Judge (Type or print)

Signature of Presiding Judge