COMMONWEALTH OF PENNSYLVANIA COUNTY OF Magisterial District Number: MDJ Name: Hon. Address: Telephone: Docket No: Date Filed: OTN: (Above to be completed by court personnel) PRIVATE CRIMINAL COMPLAINT COMMONWEALTH OF PENNSYLVANIA VS. DEFENDANT: NAME and ADDRESS (Fill in defendant222s name and address)Notice: Under Pa.R.Crim.P. 506, your complaint may require approval by the attorney for the Commonwealth before it can be accepted by the magisterial district court. If the attorney for the Commonwealth disapproves your complaint, you may petition the court of common pleas for review of the decision of the attorney for the Commonwealth. Fill in as much information as you have. Defendant222s Race/Ethnicity Defendant222s Sex Defendant222s D.O.B. Defendant222s A.K.A. (also known as) White Black Asian Native American Hispanic Unknown Female Male Defendant222s Vehicle Information Plate Number State Registration Sticker (MM/YY)I, (Name of Complainant-Please Print or Type) do hereby state: (check appropriate box) 1.I accuse the above named defendant who with violating the penal laws of the Commonwealth of Pennsylvania at in County on or about Participants were: (if there were participants, place their names here, repeating the name of the above defendant) FREE INTERPRETERwww.pacourts.us/language-rights American LegalNet, Inc. www.FormsWorkFlow.com Defendant222s Name: Docket Number: PRIVATE CRIMINAL COMPLAINT 2.The acts committed by the accused were:(Set forth a summary of the facts sufficient to advise the defendant of the nature of the offense charged. A citation to the statute allegedly violated, without more,is not sufficient. In a summary case, you must cite the specific section and subsection of the statute or ordinance allegedly violated. All of which were against the peace and dignity of the Commonwealth of Pennsylvania and contrary to the Act of Assembly, or in violation of and (Section) (Subsection) of the (PA Statute) 3.I ask that process be issued and that the defendant be required to answer the charges I have made. 4.I verify that the facts set forth in this complaint are true and correct to the best of my knowledge or information andbelief. This verification is made subject to the penalties of Section 4904 of the Crimes Code (18 Pa.C.S. 247 4904)relating to unsworn falsification to authorities. 5.I certify that this filing complies with the provisions of the Case Records Public Access Policy of the Unified JudicialSystem of Pennsylvania that require filing confidential information and documents differently than non-confidentialinformation and documents. Date Signature of Complainant Office of the Attorney for the Commonwealth Approved Disapproved because (Name of Attorney for Commonwealth-Please Print or Type) (Signature of Attorney for Commonwealth) (Date)AND NOW, on this date , I certify that the complaint has been properly completed and verified. (Magisterial District) (Issuing Authority) SEAL FREE INTERPRETERwww.pacourts.us/language-rights American LegalNet, Inc. www.FormsWorkFlow.com