Form F-5B(LE) "Affidavit of Separation Law Enforcement Officer" - North Carolina

What Is Form F-5B(LE)?

This is a legal form that was released by the North Carolina Department of Justice - a government authority operating within North Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 11, 2013;
  • The latest edition provided by the North Carolina Department of Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form F-5B(LE) by clicking the link below or browse more documents and templates provided by the North Carolina Department of Justice.

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Download Form F-5B(LE) "Affidavit of Separation Law Enforcement Officer" - North Carolina

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CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION
CRIMINAL JUSTICE STANDARDS DIVISION
Post Office Drawer 149, Raleigh, NC 27602
Telephone: (919) 661-5980
Fax: (919) 779-8210
AFFIDAVIT OF SEPARATION
Form F-5B(LE)
LAW ENFORCEMENT OFFICER
Rev. 3/11/13
Instructions
Please Type or Print all information clearly. This form shall be completed for each separation from a certified position.
The report must be submitted to the Commission NO LATER THAN 10 DAYS after FINAL SEPARATION. A copy
of this form must be retained in the Agency’s personnel file. THIS FORM MUST BE COMPLETED IN ITS
ENTIRETY.
Separating Agency: ________________________________________ Telephone Number: ______________________
Address: _________________________________________________________________________________________
Street Address/PO Box
City
Zip Code
Agency or ORI Number (If available): _________________________________________________________________
(ORI- Originating Routing Identifier assigned by NCIC)
Separated Officer’s Name: __________________________________________________________________________
First
Middle
Last
Home Address: ___________________________________________________________________________________
Date of Birth:
______________________________ Last 4 Digits of SSN:
_______________________________
Date of Oath of Office: ________________________ Length of Service:
_______________________________
Position/Rank: ______________________________
Full Time
Part Time
Date of Final Separation: ___________________________________________________________________________
Reason for Separation
Death:
Yes
No
Resignation
Dismissal
Other
Retirement
Type
:
Service
Disability
If No, check one of the boxes below:
This agency is NOT aware of any investigation(s) in the last 18 months concerning potential criminal action or
potential misconduct by this officer.
This agency IS aware of any investigation(s) in the last 18 months concerning potential criminal action or potential
misconduct by this officer.
Have criminal charges been filed?
Yes
No
1. Agency Contact Person or Investigator’s Name: _________________________________________________
2. Agency Contact Person or Investigator’s Phone Number: __________________________________________
Detailed description of reasons for investigation: Do not use generic terminology in this section such as conduct
Form F-5B(LE), Rev. 3/11/13
CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION
CRIMINAL JUSTICE STANDARDS DIVISION
Post Office Drawer 149, Raleigh, NC 27602
Telephone: (919) 661-5980
Fax: (919) 779-8210
AFFIDAVIT OF SEPARATION
Form F-5B(LE)
LAW ENFORCEMENT OFFICER
Rev. 3/11/13
Instructions
Please Type or Print all information clearly. This form shall be completed for each separation from a certified position.
The report must be submitted to the Commission NO LATER THAN 10 DAYS after FINAL SEPARATION. A copy
of this form must be retained in the Agency’s personnel file. THIS FORM MUST BE COMPLETED IN ITS
ENTIRETY.
Separating Agency: ________________________________________ Telephone Number: ______________________
Address: _________________________________________________________________________________________
Street Address/PO Box
City
Zip Code
Agency or ORI Number (If available): _________________________________________________________________
(ORI- Originating Routing Identifier assigned by NCIC)
Separated Officer’s Name: __________________________________________________________________________
First
Middle
Last
Home Address: ___________________________________________________________________________________
Date of Birth:
______________________________ Last 4 Digits of SSN:
_______________________________
Date of Oath of Office: ________________________ Length of Service:
_______________________________
Position/Rank: ______________________________
Full Time
Part Time
Date of Final Separation: ___________________________________________________________________________
Reason for Separation
Death:
Yes
No
Resignation
Dismissal
Other
Retirement
Type
:
Service
Disability
If No, check one of the boxes below:
This agency is NOT aware of any investigation(s) in the last 18 months concerning potential criminal action or
potential misconduct by this officer.
This agency IS aware of any investigation(s) in the last 18 months concerning potential criminal action or potential
misconduct by this officer.
Have criminal charges been filed?
Yes
No
1. Agency Contact Person or Investigator’s Name: _________________________________________________
2. Agency Contact Person or Investigator’s Phone Number: __________________________________________
Detailed description of reasons for investigation: Do not use generic terminology in this section such as conduct
Form F-5B(LE), Rev. 3/11/13
unbecoming, failed to meet agency standards, violation of agency procedures, etc. Detailed information describing the
unlawful act or act of misconduct is needed for efficient processing. (Attach additional sheets as necessary.)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
_______________________________
____________________________
_________________ _________
Signature of Executive Officer
Printed Name of Executive Officer
Title
Date
or Authorized Representative
or Authorized Representative
STATE OF NORTH CAROLINA
COUNTY OF ________________
I, _____________________________________, a Notary Public in and for said County
and State do hereby certify that _______________________________________ personally appeared before me this day and
acknowledged the due execution of the foregoing instrument in writing for the purposes therein expressed.
WITNESS my hand and official seal, this the ______ day of _____________, 20__.
________________________________ My Commission expires: ___________
Notary Public
Notice to Separating Officer
I have been advised of my option to provide a written attachment to this Affidavit of Separation and I HAVE
provided such written attachment.
I have been advised of my option to provide a written attachment to this Affidavit of Separation and I have NOT
provided such written attachment.
___________________________________
_______________________________
__________________
_____________
Signature of Officer
Printed Name of Officer
Title
Date
Officer Refused to Sign
Officer Unavailable to Sign
Was the officer provided with a copy of this completed Form F-5B(LE)?
Yes
No
If yes, in what manner was form provided to the officer?
In Person
Mail
Certified Mail
Other (please specify) _________________________________
________________________________________________________________________________________________
Signature of Executive Officer
Date
or Authorized Representative
Form F-5B(LE), Rev. 3/11/13
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