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Criminal Complaint Affidavit (District Justice) - Pennsylvania
| Criminal Complaint Affidavit (District Justice) Form. This is a Pennsylvania form and can be used in District Attorney Erie Local County . |
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CRIMINAL COMPLAINT AFFIDAVIT AFFIANT/VICTIM DEFENDANT NAME: _____________________________________ NAME: ______________________________________ ADDRESS: _________________________________ ADDRESS: __________________________________ CITY: ______________________________________ CITY: _______________________________________ PHONE: HOME______________________________ PHONE: HOME ______________________________ WORK ______________________________ WORK ______________________________ AGE: ____________________ AGE: ___________________ AFFIANT (IF DIFFERENT FROM VICTIM) DATE OF INCIDENT: __________________________ NAME: _____________________________________ TIME OF INCIDENT: ___________________________ ADDRESS: __________________________________ CITY: _______________________________________ DATE OF FILING: _____________________________ PHONE: HOME: ______________________________ WORK: ______________________________ YOUR RELATIONSHIP TO THE DEFENDANT: _________________________________________________________ HOW LONG KNOWN DEFENDANT: __________________________________________________________________ RELATIONSHIP TO VICTIM: ________________________________________________________________________ LOCATION OF INCIDENT: __________________________________________________________________________ WITNESSES NAME: _______________________________ NAME: ______________________________NAME: _______________ ADD: ________________________________ ADD: _______________________________ ADD: ________________ PHONE: _____________________________ PHONE: ____________________________ PHONE: ______________ NOTE: IF YOU DO NOT HAVE A PHONE PUT IN A NUMBER WHERE YOU CAN BE CONTACTED. EITHER A WORK NUMBER, A FRIEND OR FAMILY MEMBER. WERE THE POLICE CALLED AS A RESULT OF THIS INCIDENT? _________________________________________ DID THE POLICE FILE CHARGES AS A RESULT OF THIS INCIDENT? _____________________________________ DID THE POLICE SUPPLY YOU WITH A REPORT NUMBER? _____________________________________________ OFFENSE TO BE CHARGED: _______________________________________________________________________ YOUR VERSION OF FACTS: Be specific. Include in detail what led up to the incident and what actually happened. Also, why you believe the defendant is the person responsible. Include your relationship with the defendant and any previous contact you may have had. PLEASE ATTACH ALL NECESSARY DOCUMENTATION INCLUDING BU T NOT LIMITED TO COPIES OF NOTICES SENT TO DEFENDANT, CERTIFIED RECEIPTS, CANCELED CHECKS AND FINGERPRINT CARDS. Write legibly. If your complaint cannot be easily understood it will be returned. YOU MUST BE AS SPE C I F IC AS POSSI BLE IT IS IMPORTAN T THAT YOU EXPLAIN HOW YOU KNOW THE DEFE NDANT IS THE PERSON WHO COMMIT T E D THI S CRIM E AND HOW, IT CAN BE PR OVEN IN COURT. A SEPARATE COMPLAINT MUST BE FILED FOR EACH DEFENDANT. (OVE R) <<<<<<<<<********>>>>>>>>>>>>> 2On or about, ________________________________________ at approximately _______________________ (a.m.) (p.m.) at (location) I ________________________________________ being duly sworn according to law, (print your name ) depose and say the facts set forth in the forgoing affidavit are true and correct to the best of my knowledge, information and belief. I further certify that these criminal pr oceedings are not being brought for purposes of collecting civil debt. CAUTION: SECTION 4904 OF THE PENNA. CRIMES CODE MAKES IT A CRIME PUNISHABLE BY UP TO TWO (2) YEARS IN PR ISON TO MAKE UNSWORN FALSE STATEMENTS TO AUTHORITIES. SECTION 4903 MAKES IT A CRIME TO FALSELY SWEAR I N OFFICIAL MATTE RS. (your signature) SIGNED BEFORE A NOTAR Y OR DISTR ICT JUSTICE. Sworn to a subscribed before me this ____day of ________, A.D. 20 ___ ______________________ (Rev. 1/00)
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