IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF NORTH CAROLINA No. Click or tap here to enter text.
United States of America,	Declaration of Proposed Third-Party Custodian
v.
Click or tap here to enter text., Defendant.

I, Click or tap here to enter text., make the following statements under penalty of perjury in connection with the request that the defendant be placed in my third-party custody as a condition of pretrial release:

I am at least 18 years old and competent to testify.

My relationship to the defendant is:	Click or tap here to enter text.

I have known the defendant for Click or tap here to enter text..

I have regular contact with the defendant in the following ways (describe in detail how often you see or talk to the defendant and how you have contact with the defendant):

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I have been told what the defendant is charged with in this case.

I am generally familiar with the defendant’s prior criminal history (if any).

I ☐ do not have any prior felony convictions or I ☐ do have prior felony conviction(s). If prior felony convictions, describe (including date of conviction(s), nature of charge(s), and disposition):

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The defendant ☐ will or ☐ will not live in my home. If the defendant will live in your home, identify your address, all the people who live in your home, and where the defendant will sleep.

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I am ☐ employed or ☐ unemployed. If you are employed, identify your employer and typical work schedule:

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I ☐ have firearms or ammunition in my home or I ☐ do not have firearms or ammunition in my home. I understand that, if the defendant is released into my third-party custody, I cannot have firearms or ammunition in my home while the defendant resides there.

I ☐ have narcotics or controlled substances in my home or I ☐ do not have narcotics or controlled substances in my home. I understand that, if the defendant is released into my third-party custody, I cannot have narcotics or controlled substances in my home for which there is not a valid prescription.

I ☐ have a land-line telephone in my home or I ☐ do not have a land-line telephone in my home, but am willing to have one installed; I ☐ do not have a land-line telephone in my home and I am either unwilling or unable to have one installed.

The defendant’s attorney has explained to me the responsibilities of a third-party custodian. I understand my responsibilities as a third-party custodian that, if the defendant is released into my third-party custody, I am agreeing to (a) supervise the defendant in accordance with all conditions of release, (b) use every effort to assure the appearance of the defendant at all scheduled court proceedings, and (c) notify the Court immediately if I have reason to believe that the defendant has violated any condition of release or if I cannot make contact with the defendant.

I understand that my failure to uphold my responsibilities as a third-party custodian may subject me to contempt of court proceedings.

I am willing to serve as a third-party custodian for the defendant.

I would like the Court to know the following additional information:

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I declare under penalty of perjury that the foregoing is true and correct.

Date: _______________

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Signature of Third-Party Custodian

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Printed Name