TO THE SUPERIOR COURT OF ___________ COUNTY
We, _________, _________ and __________ Commissioners appointed by the Court to assess the damages that have been and will be sustained by ______________, the owner of certain land lying in ____________ County, North Carolina, which has been taken by the Department of Transportation for highway purposes, do hereby certify that we convened, and, having first been duly sworn, visited the premises, and took such evidence as was presented to us, and after taking into full consideration the quality and quantity of the land and all other facts which reasonably affect its fair market value at the time of the taking, we have determined the fair market value of the part of the land taken to be the sum of $____________ and the damage to the remainder of the land of the owner by reason of the taking to be the sum of $____________ (if applicable).
We have determined the general and special benefits resulting to said owner from the construction of the highway to be the sum of $____________ (if applicable).
GIVEN under our hands, this the _______ day of _____________, _________
____________________________ (SEAL)
____________________________ (SEAL)
____________________________ (SEAL)
N.C. Gen. Stat. § 136-109