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AOPC 411A-05 1-2 COMMONWEALTH OF PENNSYLVANIA COUNTY OF: Magisterial District Number: MDJ Name: Hon . Address: Telephone: ( ) Docket No.: Date Filed: OTN: Notice: Under Pa.R.Crim.P. 506, your complaint may require appr oval 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. Defendant’s Race/Ethnicity White Black Asian Native American Hispanic Unknown Defendant’s Sex Female Male Defendant’s D.O.B. Defendant’s Social Security Number Defendant’s SID (State Identification Number) Defendant’s A.K.A. (also known as) Defendant’s Vehicle Information Plate Number State Registration Sticker (MM/YY) Defendant’s Driver’s License Number State I, (Name of Complainant-Please Print or Type) do hereby state: (check appropriate box) 1. I accuse the above named defendant who lives at the address set forth above I accuse the defendant whose name is unknown to me but who is described as I accuse the defendant whose name and popular desig nation or nickname is unknown to me and whom I have therefore designated as John Doe with violating the penal laws of the Comm onwealth of Pennsylvania at (Place-Political Subdivision) in County on or about Participants were: (if there were participants, place their names here, repeating the name of the above defendant) PRIVATE CRIMINAL COMPLAINT COMMONWEALTH OF PENNSYLVANIA VS. DEFENDANT: NAME and ADDRESS (Above to be completed by court personnel) (Fill in defendant’s name and address) (Continuation of No. 2) AOPC 411B-05 2-2 Defendant’s Name: Docket Number: 2. The acts committed by the accused were: (Set forth a summary of the facts sufficient to advise the defendan t of the nature of the offense charged. A citation to the s tatute allegedly violated, without more, is not sufficient. In a summary case, you must cite the specif ic 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 and belief. This verification is made subject to the penalti es of Section 4904 of the Crimes Code (18 Pa.C.S. § 4904) relating to unsworn falsification to authorities. 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. Signature of Complainant (Magisterial District) (Issuing Authority) SEAL PRIVATE CRIMINAL COMPLAINT Date