REQUEST FOR CRIMINAL COMPLAINT FOR LEAD PAINT To any Justice of Clerk-Magistrate of the Housing Court: _________________________________________________________________ on behalf of the Commonwealth, on oath complains that: _________________________________________________________________ was and is the owner of residential premises located at ______________________________________________________________; wherein a child or children under the age of six (6) resides or resided; On ____________________________, 200___, a representative of the Childhood Lead Poisoning Prevention and Control Program inspected said premises and determined that paint, plaster or other materials accessible to children contained dangerous levels of lead equal to or in excess of 1.0 milligrams lead per square centimeter or 0.5% lead by dry weight as defined by the Programs regulations, 105 C.M.R. 460.020 and the public health law, Gen.L. c. 111, 194; On _____________________________, 200___, pursuant to 460.750 of the Programs regulations, 410.832 - 833 of the State Sanitary Code, and 194 of the law, the defendant was served with a written order to abate or contain such dangerous levels of lead; and from day to day thereafter, the defendant has failed to comply with the order, in violation of 460.200(A) of the Programs regulations, 410.910 of the State Sanitary Code, and 194, 197-198 of the law; each such day being a separate offense and a separate and distinct count of this Complaint; and the defendant did so willfully, intentionally, recklessly or repeatedly; On _____________________________, 200___, and from day to day thereafter the defendant has failed to abate or contain such dangerous levels of lead, in viola tion of 460.100(A) of the Programs regulations, 410.920 of the State Sanitary Code, and 197-198 of the law; each such day being a separate offense and a separate and distinct count of this Complaint; and the defendant 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 notissue. 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