JUVENILE SUMMONS AND COMPLAINT/PROMISE TO APPEAR JD-JM-95 Rev. 12-09 C.G.S. § 46b-133, 46b-120, 46b-136; Spec. Sess. P.A. 09-7, Sec. 72 STATE OF CONNECTICUT SUPERIOR COURT JUVENILE MATTERS The undersigned officer complains that: On (Month, day, year) At (Time, A.M. or P.M.) Offense town and code Name (Last, First, Initial) Department case number Date of birth Telephone number Address (Number, street and city) Sex Race State Eyes Hair Height Weight Other violated the following Laws, Ordinances or Court Orders: Statute/Ordinance number Offense(s) 1. 2. 3. 4. 5. Name and address of parent or guardian or some other responsible person or agency: Telephone number The child was released to the child's own custody, and reasonable efforts to notify and provide a copy of the written Complaint and Summons were made prior to the court date on the Summons. II. A copy of the Complaint and Summons was served (check all that apply) on the child; on the child's parent, guardian or other suitable person or agency. I. Shield number Police department Signed (Officer) Date signed Notice Of Court Appearance The child and/or parent or guardian or other suitable person or agency named above, are required to come to the Court on the date *(Hearing date to be set no less than five (5) business days or more than ten (10) business days from issuance, based on arraignment dates.) and at the location shown below. Hearing date Time of hearing __.M Hearing date Court location (Number, street and town) Court location Promise To Appear — Child I, the child named above, was given a copy of this Juvenile Summons and I Promise To Come to the Superior Court, Juvenile Matters, at the date, time and location specified above. I understand that a parent or guardian must accompany me when I appear in court. If I do not come to court as promised, I understand that the Court may issue a warrant for my arrest. Signed Date signed Right to counsel: You have a right to be represented by an attorney. If you want an attorney but cannot pay for one and if you give proof that you cannot pay, you can apply to the Court for an attorney to be appointed for you. Your request should be made immediately at the court office where your hearing is to be held. Right to remain silent: You have the right to not make any statements; any statements you make may be introduced in evidence and used against you. Promise To Appear — Parent I, the parent, guardian or other suitable person or agency named above, Promise To Come with the child to the Superior Court, Juvenile Matters at the date, time and location specified above. If I do not come to Court as promised, I may be punished for contempt by a fine of up to $100 or imprisonment up to 6 months. Signed Relationship Date signed Signed Relationship Date signed Distribution: White —- To Juvenile Clerk w/Incident Report Green — Parent/Guardian/Custodian Yellow — Child Pink — Police Officer Gold — Prosecutorial Official American LegalNet, Inc. www.FormsWorkFlow.com