This report has been redacted to prevent the disclosure of personally identifiable information.

THIS REPORT IS FOR THE USE OF THE DIVISION OF MOTOR VEHICLES. THE DATA IS 8
DMV-349 (Rev. 1/09) COLLECTED FOR STATISTICAL ANALYSIS AND SUBSEQUENT HIGHWAY SAFETY
1 PROGRAMMING. DETERMINATIONS OF "FAULT" ARE THE RESPONSIBILITY OF INSURERS OR Do not write in these spaces
OF THE STATE'S COURTS.
No. of Units Involved Form 1 of 1 Supplemental Report Non-Reportable
9

1 Date Received by DMV

Date County Time Local Use/Patrol Area
1
09/17/2017 CABARRUS 04:14 170917020EA - 02
10
2 L 33 Relation to Crash In X
2 Occurred MOUNT PLEASANT or 02.90 Miles outside municipality 19
1 O Roadway Surface
X Near Municipality
N S E W
C X
A on SR 1006 (R.R. Crossing # 00.10 Miles ft.
Ramp or N S E W
3 T Highway Number, or Highway, Street. (If ramp or service road, indicate on line)
Service Road
At Latitude 11
I SR 2415
1 SR 2416 X
O
X From Use Highway Number, Street Name or Adjacent County or State Line
toward
Use Highway Number, Street Name or Adjacent County or State Line
Longitude 5
N N S E W
Altitude

OTHER
UNIT # 1 X VEHICLE PEDESTRIAN HIT & RUN COMMERCIAL UNIT # VEHICLE PEDESTRIAN HIT & RUN
20 VEHICLE
Driver HUNTER SCOTT MOORE Driver
4 First Middle Last First Middle Last

1 Address 4817 MOUNT PLEASANT RD Address

5 12
City ROCKWELL State NC Zip 28138-8792 City State Zip
0
Same Address on Driver's Driver's H Same Address on Driver's Driver's H
(704) 279-8717 13
License? X Yes No Phone License? Yes No Phone
Numbers W Numbers W
6 D.L. D.L.
D.L.# REDACTED C State NC D.L.#
Class
State
Class
2 CDL License CDL License
14
34 Vision 35 Physical 36 D.L. 34 Vision 35 Physical 36 D.L.
DOB REDACTED 0 1 0 DOB 7
Obstruction Condition Restrictions Obstruction Condition Restrictions

37 Alcohol/ 38 Alcohol/ 39 Results 40 Vehicle 37 Alcohol/ 38 Alcohol/ 39 Results 40 Vehicle 15

7 0 0 0
Drugs Suspected Drugs Test (if known) Seizure (DWI) Drugs Suspected Drugs Test (if known) Seizure (DWI)
5
Owner JEFFERY SCOTT MOORE Owner 16
Same as Driver? Same as Driver?

Address 4817 MOUNT PLEASANT RD Address

Same Address as Driver? Same Address as Driver? 17

City ROCKWELL State NC Zip 28138-8792 City State Zip
Plate Plate Plate Plate
Plate # WZM1032 NC 2018 Plate # 18
State Year State Year

VIN 2GCEC19T141180437 VIN

19
Vehicle Vehicle 41 Vehicle 42 Vehicle Yes Vehicle Vehicle 41 Vehicle 42 Vehicle Yes
Make CHEV Year 2004 Style (Type) 2 Drivable Make Year Style (Type) Drivable
X No No
44 Estimated 44 Estimated
43 TAD R&T-5 Damage $5,000.00 43 TAD Damage
Insurance Insurance
NORTH CAROLINA FARM BUREAU
Company Company
Policy # 8106737 Policy #

20 COMMERCIAL VEHICLE: Cargo, Carrier Name, Address, Source Carrier Identification Numbers, GVWR, Axles

Unit 45 Cargo Body Type Same Address as owner? Source:

US DOT# ICC# Axles on Vehicle
Truck Including Trailers
Shippin State State # IFTA#
g
FEI# Fleet # Gross Vehicular
Driver
Weight Rating

21 22 23 24 25 26 27 28 29 30 31 32
A Unit 1-Drv 1, Ped 1, etc. see above
1 1 1 see above W M 2 1 0 2 1 5 Veh# 1 Towed To/By: CARTERS TOWING / CARTERS TOWING

B Unit 2-Drv 2, Ped 2, etc. see above

see above
Veh# Towed To/By:

46 Name of EMS 46 Name of EMS

47 Injured Taken 47 Injured Taken

by EMS to by EMS to
(Treatment Facility and City or Town) (Treatment Facility and City or Town)
 This report has been redacted to prevent the disclosure of personally identifiable information.
Form 1 of 1 Local Use/Patrol
Area:
170917020EA - 02
48 POINTS OF INTIAL Unit # VEHICLE INFO ROADWAY INFO WORK ZONE RELATED
1 18,19,20
CONTACT Veh # 1 Veh #
(Write in Codes) Unit # 5
60 Authorized Speed Limit
55 69 Road Feature
0 78 Work Zone Area

CRASH SEQUENCE (Unit 61 Estimate of Original Traveling 70 70 Road Character 7 79 Work Activity
Unit # 1 Unit #
Speed
Level)
49 Vehicle Maneuver/Action 4 62 Estimate of Speed at Impact 65 71 Road Classification 4 80 Work Area Marked

50 Non-Motorist Action 63 Tire Impressions Before Impact (ft.) 171 72 Road Surface Type 3 81 Crash Location

51 Non-Motorist Location Prior to 64 Distance travelled After Impact (ft.) 66 73 Road Configuration 2 TRAILER INFO. Unit # Unit #
Impact 1
52 Crash Sequence - First Event for 1 65 Emergency Vehicle Use 74 Access Control 1 82 Trailer Type 0
this Unit
53 Crash Sequence - Second Event 58 66 Post Crash Fire (if 'Yes' check 75 Number of Lanes 2 1st Trailer No. Axles
block)
Width (inches)
54 Crash Sequence - Third Event 5 67 School Bus - Contact Vehicle 76 Traffic Control Type 13
Length (feet)
55 Crash Sequence - Fourth Event 68 School Bus - Noncontact Vehicle 77 Traffic Control Oper 1
2nd Trailer No. Axles
56 Most Harmful Event for this Unit 5 Width (inches)
COMMERCIAL VEHICLE: Hazardous Material
Unit
57 Distance/Direction of Object Struck 2 Involvement
Haz Mat Placard Yes No From Placard indicate Length (feet)
4-digit placard number or 1-digit number from
58 Vehicle Underride/Override 3 Hazardous No
Yes name from diamond or bottom of diamond 83 Unit #
Cargo Released Overwidth Permit
box
(Does not include fuel from fuel tank) Overwidth Trailer #
59 Vehicle Defects 0 Carrying Haz Mat
and Overwidth
Yes No Mobilehome

84 DIAGRAM

Indicate
North

X Traveling Traveling
Unit # 1 was X on SR 1006 Unit # was on

Parked N S E W Parked N S E W
Facing Facing
(include pertinent unusual aspects which are
VEH.1
WAS TRAVELING NORTH ON SR 1006. VEH.1 RAN OFF THE ROAD TO THE RIGHT, COLLIDED WITH A DITCH AND OVERTURNED. VEH.1
85 NARRATIVE not listed elsewhere on the form)
CAME TO REST IN THE NORTHBOUND LANE OF SR 1006 FACING WEST ON ITS SIDE.

ADDITIONAL PROPERTY DAMAGE

86 Type/ State Estimated
Owner
Owner Property? Damage $
Address

WITNESSES
Name Address Phone No

Name Address Phone No.

TRAFFIC VIOLATION(S)
Name Charge(s)
(Citation # optional)

Name Address

Officer Name Officer Number Department Date of Report

TRP. J M BARNHARDT 2860 NC STATE HIGHWAY PATROL NCNHP0000 09/17/2017