COMMONWEALTH OF PENNSYLVANIA 

COUNTY  OF      

Magisterial District Number: 

MDJ Name:  

Hon.    

Address: 

Telephone: 

Docket No:  

Date Filed: 

OTN: 

PRIVATE  
CRIMINAL COMPLAINT 

COMMONWEALTH OF PENNSYLVANIA 
VS. 
NAME and ADDRESS 

DEFENDANT: 

(Above to be completed by court personnel) 

(Fill in defendant’s name and address)

Notice: Under Pa.R.Crim.P. 506, your complaint may require approval 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. 

Defendant’s Race/Ethnicity 

Defendant’s D.O.B. 

Defendant’s A.K.A. (also known as) 

Defendant’s Vehicle Information 
Plate Number           State       

 Registration Sticker (MM/YY) 

Fill in as much information as you have. 

 White   

 Black 

 Asian    

 Native American 

 Hispanic 

 Unknown 

Defendant’s 
Sex 

 Female 

 Male 

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 designation  or nickname  is  unknown  to  me  and  whom I 
have therefore designated as John Doe. 

with violating the penal laws of the Commonwealth 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) 

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Defendant’s  Name: 

Docket  Number:     

PRIVATE  
CRIMINAL COMPLAINT 

2.

The  acts  committed  by  the  accused  were:
(Set forth a summary of the facts sufficient to advise the defendant of the nature of the offense charged.  A citation to the statute allegedly violated, without more,
is not sufficient.  In a summary case, you must cite the specific 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 
and        
Assembly,  or  in  violation  of             

(Section) 

(Subsection) 

of the 

(PA Statute) 

3.

4.

5.

I ask that process be issued and that the defendant be required to answer the charges I have made.

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 penalties of Section 4904 of the Crimes Code (18 Pa.C.S. § 4904)
relating  to  unsworn  falsification  to  authorities.

I certify that this filing complies with the provisions of the Case Records Public Access Policy of the Unified Judicial
System of Pennsylvania that require filing confidential information and documents differently than non-confidential
information and documents.

Date 

Signature of Complainant 

      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. 

(Magisterial District) 

 (Issuing Authority) 

SEAL

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