N.C. Gen. Stat. § 47-43.3
When the execution of an instrument is proved by proof of the signature of the maker as provided by G.S. 47-12.1 or as provided by G.S. 47-13, the certificate required by G.S. 47-13.1 shall be in substantially the following form:
STATE OF______________________________________________
(Name of state)
_________________________________________ COUNTY
I, _______________________________, a __________________________________
(Name of officer taking proof) (Official title of officer taking proof)
of___________________ COUNTY, _______________________________, certify that
(Name of state)
_______________________________________ personally appeared before me this day,
(Name of person familiar with
maker's handwriting)
and being duly sworn, stated that he knows the handwriting of______________________
(Name of maker)
and that the signature to the foregoing instrument is the signature of _________________
(Name of maker)
WITNESS my hand and official seal, this the ____ day of _________________, ____
(Month) (Year)
__________________________________________
(Signature of officer taking proof)
__________________________________________
(Official title of officer taking proof)
My commission expires _______________________________________________
(Date of expiration of officer's commission)
N.C. Gen. Stat. § 47-43.3