Box |
Description |
1
|
District Court Number
|
| 2 |
Docket Number |
| 3 |
Defendant's Social Security # |
| 4 |
District Court Address |
| 5 |
Defendant's Driver's License # |
| 6 |
State Issuing Driver's Licence |
| 7 |
Defendant's Name |
| 8 |
Defendant's Address |
| 9 |
Defendant's Race/Ethnicity |
| 10 |
Sex of Defendant |
| 11 |
Defendant's Date of Birth |
| 12 |
Resident Status |
| 13 |
Case Initiated by Arrest or Citation |
| 14 |
Juvenile – Yes or No |
| 15 |
Parent Notified – Yes or No |
| 16 |
Parent Name |
| 17 |
Date of Parental Notification
(if by officer)
|
| 18 |
Time of Parental Notification
(if by officer) |
| 19 |
Charge |
| 20 |
Nature of Offense |
| 21 |
PA Code (not used) |
| 22 |
Indicates Statute or Ordinance |
| 23 |
Section Charged |
| 24 |
Subsection Charged |
| 25 |
Amount of Fine (fine set by Magisterial District Judge) |
| 26 |
Court Costs
(added State cost) |
| 27 |
Judicial Computer Project/
Access to Justice Court
(added State cost) |
| 28 |
Total Fines & Costs Due
(call court for total) |
| 29 |
Lab Services Requested |
| 30 |
Date of Offense |
| 31 |
Time of Offense
|
| 32 |
Day of Offense |
| 33 |
Municipality of Offense
|
| 34 |
Code (not used) |
| 35 |
Zone (not used) |
| 36 |
Location of Offense |
| 37 |
County of Offense |
| 38 |
County Code |
| 39 |
Defendant's Signature |
| 40 |
Date Citation Issued |
| 41 |
Filed on Information Received |
| 42 |
Officer's Signature & Badge # |
| 43 |
Police Station Address |
44-
49
|
For Police Use Only |
| 50 |
Victim's Name |
| 51 |
Victim's Date of Birth |
| 52 |
Victim's Sex |
| 53 |
Victim's race |
| 54 |
Victim's Address (not visible on Defendant's copy of citation) |
| 55 |
Victim's Phone # (not visible on Defendant's copy of citation) |
| 56 |
Officer's Remarks or
Subpoena Lists |
