27 CAR § 30-149. Form of the affidavit

Any affidavit filed pursuant to this subsection must include, but shall not be limited to the following items: (1) Date and location of accident; (2) Effective date of suspension; and (3) Statement that one (1) year has elapsed since the effective date of suspension and that during such period no action at law has been instituted and is pending as a result of the accident, nor has any judgment been rendered which remains unsatisfied.