THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) LAND USE CITATION LOCAL LAND USE CITATION, TOWN/CITY OF You MUST COME TO COURT AT o222clock AM PM on to answer this citation You DO NOT HAVE TO COME TO COURT but must answer this citation by o222clock AM PM . Follow the instructions on page 2 of this Summons. County of Court (Town/City State Zip) THE UNDERSIGNED COMPLAINS THAT CONTRARY TO RSA 676 THE DEFENDANT: (Please Print) (Last Name) (First Name) (MI) (Address) (City/Town) On was given written notice of the Violation that on the (narrative to include the circumstances of the violation and place the violation occurred): (Zip) After written notice, the violation was again witnessed on at AM/PM / (Prosecuting Official Signature) (Title/Authority) SERVED IN HAND Civil Penalty $ Maximum $275 per citation for the first offense and $550 per citation for subsequent offenses for each day the violation continues. Pursuant to RSA 676:17 I State of , County of This instrument was acknowledged before me on by My Commission Expires Affix Seal, if any Signature of Notarial Officer / Title NHJB-2332-D (07/27/2007) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: LOCAL LAND USE CITATION INSTRUCTIONS Unless you have been instructed to come to court in person, you may answer this complaint by mail or may personally appear in court on the date on the first page of this summons. If you enter a plea by mail, you have four choices regarding this summons. You must (X) one of the following choices, sign below, and return this Summons to the court no later than the date shown on the first page of this Summons. Checks and money orders shall be made payable in U.S. FUNDS ONLY to the court whose name and address appear on the first page of this Summons. DO NOT SEND CASH THROUGH THE MAIL. FAILURE TO RESPOND ON OR BEFORE THE DATE SHOWN ON THE FIRST PAGE OF THIS CITATION MAY RESULT IN YOUR ARREST. 1. I plead NOT GUILTY and wish to have a trial. I understand that I DO NOT HAVE TO APPEAR IN COURT ON OR BEFORE THE DATE SHOWN ON THE FIRST PAGE OF THIS SUMMONS and that I will be notified by mail when and where to appear for trial. I understand I have the right to represent myself of to hire a lawyer at my own expense. 2. I plead GUILTY or NO CONTEST and have enclosed a check or money order for the TOTAL amount of my civil penalty. 3. I have been charged with an offense for which no fine amount is shown on the front of this Summons, I wish to plead GUILTY or NO CONTEST and to be notified of the amount of my fine by mail. WARNING 1. Defendants who are issued a summons and local land use citation and who wish to plead guilty or nolo contendere shall enter their plea on the summons and return it with payment of the civil penalty, as set forth in the citation, to the clerk of the court prior to the arraignment date, or shall appear in court on the date of arraignment. 2. Failure to respond to this summons by the date shown on the front of this summons, or failure to appear for the hearing scheduled with regard to this summons will result in a $50.00 administrative fee added to your civil penalty (RSA 676:17) 3. If you default in accordance with Paragraph 2, or fail to pay any penalty or comply with any order with regard to this summons or a similar order on any matter within the court222s discretion, or issue a bad check in payment of a fine or other penalty, the court may in its discretion, issue a bench warrant for your arrest. Date Signature Address if different than on summons NHJB-2332-D (07/27/2007) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com