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COMMONWEALTH OF PENNSYLVANIA
CIVIL COMPLAINT
Magistlnal Olllllel Number
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PLAINTIFF
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COMPLAINT NUMIlI n CV
DATE mEn
DEFENDANTIS):
VS,
AMOUNT
DA TE PAID
0.1 Name
A/'Hj'I'~S'
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FILING COSTS
SERVICE COSTS
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1.50
0,2 NafTw
Addfess
TOTAL $
" .' T~ THE DEFENDANT:
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Tho above named plotnlilllsl85ks judgmonl against you lor $ together wllh costs upon
the following clOlm (CIVil Flnos must Include Cllollan ollhe statuto or ordlnonce violated):
~ 19~J,6 VI,:;'" CatU h;crJl;ltt :>.;, ,t.:ui-/;':W-':,JJV-1VJ~ ~(j QlleLlCltl tor tile; 6ilwe lllhlllU1
-'det'MdMt(Ii). 'fr", loa;, ill ,'.~~'Itlt in Ilet'NI1-" t01' ~~ ,!.alII. \i.c .1t"e lUlk1nJ {\it' jl.ll.l;,r'lIo1llt
fur tlla belen:c UU<' riu:: 'ICCCLlllI.. lut(!J.'I!lIt e.; \tel! ell) (OJ: ul! ctdtli au.! L"ClI4U1lillllc a Ll0111ft)'
feu, 11' IlCt;.e:lSlU)'. '
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_ '., "I, ,L.u;".Lilil~ i..:r.!J.'l,-,.\.'L li~l:dl"1UI(d'l L~l"JG1( l;"nil. . verily Ihet Iho laCI..ellqrlh
. 11\ this complaint ora truo and torrecl to thobcst'ot mv 'knowICd~O. information, and boliof, This st8tttmo'nlls madesUblectto tho ponaUios 01
Section 4904 01 tho Crimos Cude (18 Pn C SA' 4904, relnled 10 11l15Worn fnlsillcnllon 10 outhorilios,
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(Signature 01 Plainllll or Authorized Agenl)
Plalnllll',
Allomey:
Addre..:
Telephone:
HEARING IS SCHEDULED BY DISTRICT JUSTICE AS FOLLOWS:
location
Dlllo
Time
IF YOU INTEND TO ENTER A DEFENSE TO THIS COMPLAINT, NOTIFY THIS OFFICE IMMEDIATELY AT
THE ABOVE TELEPHONE NUMBER, YOU 'MUST APPEAR' AT 'THE 'HEAnlNG AND PRESENT YOUR
DEFENSE, UNLESS YOU DO, JUDGMENT WILL BE ENTERED AGAINST YOU BY DEFAULT.
IF YOU HAVE A CLAIM ilg""15llho 1'1","1111 WllIeh 15 Wllhll' d15lftcl JusllCo IUftsdicl,on and which you ,nlend 10 assml allho
hearing, you must Ide II un it complaint lorm ilt this olllcu itlleasl hVl: 151 days lwforo tho dalo set fur 'he hoaring II you have it
claim against the plillllldt which IS nut wllhm dlslHClllISllCH IUFISdlClllHl you may request mlormAtiun from thiS offico as 10 the
proccdurc5 you may follow
Service of Process
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