STATE OF NORTH CAROLINA
County
File No.
In The General Court Of Justice
District Court Division - Small Claims
Name And Address Of Plainti
AFFIDAVIT AS TO CDC
DECLARATION FORM
(Summary Ejectment)
CAUTION: The clerk of superior court cannot give you legal
advice. If you have legal questions, you should consult with an
attorney before ling a complaint for summary ejectment.
N.C. Exec. Order No. 171 (Oct. 28, 2020)
Name And Address Of Defendant 1
Name And Address Of Defendant 2
VERSUS
I, the undersigned, attest the following:
1. I am the (check one)
Plaintiff authorized agent (or attorney) of the Plaintiff in the instant action.
2. Plaintiff is seeking to recover possession of the following leased premises (“Premises”):
Name of Apartment Community
(if any)
:
Street Address and Unit No.
(if any)
,
City, County, State, Zip:
3.
(complete a. or b.)
a. I am the landlord of the above-described premises and I DID DID NOT provide each residential tenant of those
premises with a blank copy of the CDC Declaration form.
(See Section 2 of N.C. Exec. Order No. 171.)
b. I am an agent of or attorney for the landlord of the above-described premises and the landlord DID DID NOT
provide each residential tenant of those premises with a blank copy of the CDC Declaration form.
(See Section 2 of N.C. Exec.
Order No. 171.)
AFFIDAVIT
DECLARATION
IF SIGNED BY AN ATTORNEY FOR PLAINTIFF: In accordance with Rule 11 of the N.C. Rules of Civil Procedure, I have read the statements
contained here, and I hereby certify that, to the best of my knowledge, information, and belief formed after reasonable inquiry, that such statements are
well-grounded in fact and that they are submitted in good faith and not interposed for any improper purpose.
IF SIGNED BY PLAINTIFF OR NON-ATTORNEY AGENT FOR PLAINTIFF: I hereby declare, under penalty of perjury, that the statements
made herein are true and correct to the best of my knowledge.
Date
Signature Of Declarant
Name And Address Of Declarant
AOC-CVM-208, New 1/21
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