REQUEST FOR CRIMINAL COMPLAINT FOR STATE SANITARY CODE VIOLATIONS To any Justice or 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 ________________________________________________________________; On ____________________________, 200___, a representative of the _________________ ________________________ ___________Program inspected the said premises and determined that the dwelling did not comply with the provisions of Article II of the State Sanitary Code, 105 C.M.R., 410.000; On _____________________________, 200___, pursuant to 410.832 - 833 of the Code, the defendant was served with a written order to comply; On _____________________________, 200___, and from day to day thereafter the defendant has failed to comply with the order, each such day being a separate offense and a separate and distinct count of this Complaint; all in violation of State Sanitary Code, 105 C.M.R., 410.910-920, and the public health law, Gen.L. c. 111, 127A, 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 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