SAMPLE NONCRIMINAL MUNICIPAL CITATION FORM
FOR USE PURSUANT TO G.L. C. 40, § 21D
APPROVED BY THE CHIEF JUSTICE OF THE DISTRICT COURT DEPARTMENT
EFFECTIVE MARCH 21, 1991

CITY [or TOWN] OF [Name] NOTICE OF VIOLATION
OF CITY ORDINANCE [or TOWN BY-LAW], RULE OR REGULATION

DATE OF NOTICE

NOTICE NO.

NAME OF OFFENDER

ADDRESS OF OFFENDER

CITY, STATE, ZIP CODE

DOB OF OFFENDER

MV OPERATOR LICENSE NO.

MV/MB REGISTRATION NO.

OFFENSE (s)

I HEREBY ACKNOWLEDGE RECEIPT OF THE FOREGOING CITATION

         G Unable to obtain signature of offender.      Date Mailed _________________

THE NONCRIMINAL FINE FOR THIS OFFENSE IS $ _________________.
YOU HAVE THE FOLLOWING ALTERNATIVES IN THIS MATTER:
Either option (1) or option (2)  will operate as a final disposition, with no resulting criminal record.

(1)    You  may  pay  the  above  noncriminal  fine,  either  by  appearing  in  person  or
through an authorized agent, or by mailing a check, money order or postal note WITHIN
21 DAYS OF THE DATE OF THIS NOTICE to:

X  

[City or Town Clerk]
[Address].

(2)    You  may  contest  this  matter  by  making  a  written  request  for  a  noncriminal
hearing before a court magistrate WITHIN 21 DAYS OF THE DATE OF THIS NOTICE
Clerk-Magistrate, [Name] District Court
to: 
[Address]
Attn: 21D Noncriminal hearings.

(3)  If you do not pay the noncriminal fine or request a hearing within 21 days, or if
you  do  not  appear  for  the  hearing  or  pay  any  fine  determined  to  be  due,  a  criminal
complaint may be issued against you.

G I elect Option (1) above, confess the violation charged, and enclose payment by
check, money order or postal note in the amount of $ ________________.  I have written
the number of this notice on my check, money order or postal note, or enclosed a copy
of this notice.
G I elect Option (2) above and request a noncriminal hearing on this matter.  I have
enclosed a copy of this notice and my name and current address.

Signature ___________________________________________________________

SIGNATURE OF ENFORCING PERSON

ENFORCING DEPT.

DATE & TIME OF VIOLATION

LOCATION OF VIOLATION