REQUEST FOR CRIMINAL COMPLAINT To any Justice or Clerk-Magistrate of the Housing Court: _________________________________________________________________ on behalf of the Commonwealth, on oath complains that: Name and Address of Defendant: Statute violated: _____________________________ _________________________ _____________________________ _____________________________ Possible penalties: _____________________________ _________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ and did so willfully, intentionally, recklessly or repeatedly. __________________________ ______________________________ Date: Complainant: Assigned for hearing on _____________________,200__, at _________ oclock. On hearing (Complainant)(Defendant)(both parties)(neither party) , I find no probable cause for the Complaint. Process shall not issue. On hearing (Complainant)(Defendant)(both parties)(neither party) , and Complainant having sworn or affirmed that the Complaint is true upon information and belief, I find probable cause, and order summons to issue returnable ____________________________. ________________________ _________________________________ Date: Clerk-Magistrate American LegalNet, Inc. www.USCourtForms.com