CR-215A, 04/09 Probable Cause Statement 247970.01 Wisconsin Statutes; 4th Amendment, US Constitution This form shall not be modified. It may be supplemented with additional material. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY Name of Arrested Person Date of Birth Probable Cause Statement Agency Case No. Case No. 1. I state as follows: A. I am the arresting officer in this case OR B. I am a law enforcement officer and make this statement on information and belief. 2. The above - named person was arrested without a warrant on at a.m. p.m. How identified: verbally WI D.L. Other: (Specify) 3. I have probable cause to believe that the arrested person committed the following offense(s): Offense(s) Statute Number(s) Offense(s) Statute Number(s) 1. 2. 3. 4. 4. Information for following summary provided by: Alleged Victim: Other: 5. I believe the arrested person committed this offense(s) because t he alleged victim(s) did did not consent to the above listed offense(s): Summarize below and/or See documentation attached. State of: County of: Su bscribed and sworn to before me on: Notary Public, State of Wisconsin Print or Type Name My commission expires: Person completing A ffidavit Name Printed or Typed Badge Number/Department a.m. p.m. Date Time Telephone Conference Call Determining Probable Cause The initial probable cause was determined by a telephone conference call. The judge/commissioner instructed me to affix the decision, his/her signature, and date and time in the appropriate location, to be countersigned later by the judge/commissioner. Name Printed or Typed American LegalNet, Inc. www.FormsWorkFlow.com