STATE OF NORTH CAROLINA,                                IN THE GENERAL COURT OF JUSTICE
                                                                      DISTRICT COURT DIVISION
COUNTY OF SAMPSON                                          FILE NO.  ____________________
                                                                       FILM NO.  ____________________                                     




STATE OF NORTH CAROLINA,               
    PLAINTIFF                       
                                                             AFFIDAVIT OF PRIOR RECORD
                                                             BY RESPONDENT/DEFENDANT
VS.                                                        
   
                              
____________________________,                    
   DEFENDANT        





I, _______________________________________, do hereby certify and swear under
penalty of perjury that I have not received an Improper Equipment in any jurisdiction within the
State of North Carolina within the last three years.  I understand that this information will be
relied upon by the State of North Carolina in making it's determination as to the disposition of
my charge.  I further understand that if I provide false information in this affidavit that I am
subject to criminal prosecution by the State of North Carolina in the above referenced county.

This the _____ day of _______________________, 200__.

                                                                           __________________________________
                                                                           RESPONDENT/DEFENDANT

SUBSCRIBED AND SWORN BEFORE ME

THIS THE _____ DAY OF _____________, 200__.


_______________________________________                                                                          
NOTARY PUBLIC

MY COMMISSION EXPIRES: ________________