20_362564_proof_01.pdf

½ in False Stub

362564 PT1 FACE INK: BLACK

State of Michigan Department of Natural Resources

Date of Issue

The Undersigned, Being Duly Sworn States That on, or Has Reasonable Cause To Believe That On or About Agency Use

Month Day Year At Approx AM

PM

Day of Week

YES NO

Name (First, Middle, Last)

Street

City State ZIP

State Driver’s License Number

Race Sex Date of Birth Height Weight Hair Eyes Scars or Marks

Type Vehicle Plate No. Year State Vehicle Description (Make, Model, Color)

Employed

The Person Named Above did in Violation of 1. State Law 2. Local Ordinance

3. Administrative Rule 4. Commission Order 5. Directors Order 6. Tribal

At or Near

Within City Village Township of

County of Did the Following

C/I Warn Conservation Fee

Misd Fug Fel

YES NO

A

C/I Warn Conservation Fee Misd Fug Fel

YES NO

B

Seized Property YES NO If yes, Describe

Damage to Property Local Court Bond $ Vehicle Impounded Injury License Posted in Lieu of Bond

Traffic Crash Death Appearance Certificate

Person in Active Military Service YES NO None

Appearance Date on or Before

Hearing Date (if Applicable ) on Contact Court Juvenile Traffic Misd. (Court Will Notify) Formal Hearing Required (Court Will Notify)

In the Court of

Court Address & Telephone

I Served a Copy of the Civil Infraction Complaint Upon the Defendant.

Officer’s Name (Please Print) Officer’s ID No.

I declare under the penalties of perjury that the statements above are true to the best of my information, knowledge, and belief.

Complainant’s Signature and Receipt if Applicable Date

Agency’s ORI Agency Name

Court Copy

PR

PR

000001

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000001

½ in False Stub

362564 PT2 FACE INK: BLACK

Has Reasonable Cause To Believe That On or About Agency Use

Month Day Year At Approx AM

PM

Day of Week

YES NO

Name (First, Middle, Last)

Street

City State ZIP

State Driver’s License Number

Race Sex Date of Birth Height Weight Hair Eyes Scars or Marks

Type Vehicle Plate No. Year State Vehicle Description (Make, Model, Color)

Employed

The Person Named Above did in Violation of 1. State Law 2. Local Ordinance

3. Administrative Rule 4. Commission Order 5. Directors Order 6. Tribal

At or Near

Fel

YES NO

A

C/I Warn Conservation Fee Misd Fug Fel

YES NO

B

Seized Property YES NO If yes, Describe

Damage to Property Local Court Bond $ Vehicle Impounded Injury License Posted in Lieu of Bond

Traffic Crash Death Appearance Certificate

Person in Active Military Service YES NO None

Appearance Date on or Before

Hearing Date (if Applicable ) on Contact Court Juvenile Traffic Misd. (Court Will Notify) Formal Hearing Required (Court Will Notify)

In the Court of

Court Copy

PR

PR

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362564 PT3 FACE INK: BLACK

Has Reasonable Cause To Believe That On or About Agency Use

Month Day Year At Approx AM

PM

Day of Week

YES NO

Name (First, Middle, Last)

Street

City State ZIP

State Driver’s License Number

Race Sex Date of Birth Height Weight Hair Eyes Scars or Marks

Type Vehicle Plate No. Year State Vehicle Description (Make, Model, Color)

Employed

The Person Named Above did in Violation of 1. State Law 2. Local Ordinance

3. Administrative Rule 4. Commission Order 5. Directors Order 6. Tribal

At or Near

Fel

YES NO

A

C/I Warn Conservation Fee Misd Fug Fel

YES NO

B

Seized Property YES NO If yes, Describe

Damage to Property Local Court Bond $ Vehicle Impounded Injury License Posted in Lieu of Bond

Traffic Crash Death Appearance Certificate

Person in Active Military Service YES NO None

Appearance Date on or Before

Hearing Date (if Applicable ) on Contact Court Juvenile Traffic Misd. (Court Will Notify) Formal Hearing Required (Court Will Notify)

In the Court of

PR

PR

000001

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Verdict / Determination Date Amended Charge

1 Guilty 2 Guilty as Amended 3 Not Guilty 4 Nolle Prosequi

5 Dismissed 6 Responsible 7 By Default 8 Not Responsible

9 Deferred 10 Delayed

Fines

Costs

State Fees

Reimbursement

Judgment fee

Additional Sanctions (Restitution) To be Paid by

License Revocation

I understand that i am ineligible to secure the licenses checked below until after the date of

(AL) All Licenses (D) Deer

(AHAF) All Hunt and Fish (B) Bear

(AHAT) All Hunt and Trap (AT) All Trap

(AH) All Hunting (AF) All Fish

(DB) Deer and Bear Other

Defendant’s Signature

Judge / Magistrate / Clerk

Verdict / Determination Date Amended Charge

1 Guilty 2 Guilty as Amended 3 Not Guilty 4 Nolle Prosequi

5 Dismissed 6 Responsible 7 By Default 8 Not Responsible

9 Deferred 10 Delayed

Fines

Costs

State Fees

Reimbursment

Judgement fee

Additional Sanctions (Restitution) To be Paid by

License Revocation

I understand that i am ineligible to secure the licenses checked below until after the date of

(AL) All Licenses (D) Deer

(AHAF) All Hunt and Fish (B) Bear

(AHAT) All Hunt and Trap (AT) All Trap

(AH) All Hunting (AF) All Fish

(DB) Deer and Bear Other

Defendant’s Signature

Judge / Magistrate / Clerk

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Has Reasonable Cause To Believe That On or About Agency Use

Month Day Year At Approx AM

PM

Day of Week

YES NO

Name (First, Middle, Last)

Street

City State ZIP

State Driver’s License Number

Race Sex Date of Birth Height Weight Hair Eyes Scars or Marks

Type Vehicle Plate No. Year State Vehicle Description (Make, Model, Color)

Employed

The Person Named Above did in Violation of 1. State Law 2. Local Ordinance

3. Administrative Rule 4. Commission Order 5. Directors Order 6. Tribal

At or Near

Fel

YES NO

A

C/I Warn Conservation Fee Misd Fug Fel

YES NO

B

Seized Property YES NO If yes, Describe

Damage to Property Local Court Bond $ Vehicle Impounded Injury License Posted in Lieu of Bond

Traffic Crash Death Appearance Certificate

Person in Active Military Service YES NO None

Appearance Date on or Before

Hearing Date (if Applicable ) on Contact Court Juvenile Traffic Misd. (Court Will Notify) Formal Hearing Required (Court Will Notify)

In the Court of y

Officer – Prosecutor Copy

Agenc ’s ORI Agency Name

PR

PR

000001

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Indicate disposition of all seized property. Obtain signed receipts as needed.

The property listed on the front of this ticket was returned to me in the same condition as when it was seized.

Defendants Signature Date

The property listed on the front of this ticket has been properly disposed of, or turned over to my control.

District Supervisor Authorized Signature Date

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Has Reasonable Cause To Believe That On or About Agency Use

Month Day Year At Approx AM

PM

Day of Week

YES NO

Name (First, Middle, Last)

Street

City State ZIP

State Driver’s License Number

Race Sex Date of Birth Height Weight Hair Eyes Scars or Marks

Type Vehicle Plate No. Year State Vehicle Description (Make, Model, Color)

Employed

The Person Named Above did in Violation of 1. State Law 2. Local Ordinance

3. Administrative Rule 4. Commission Order 5. Directors Order 6. Tribal

At or Near

Fel

YES NO

A

C/I Warn Conservation Fee Misd Fug Fel

YES NO

B

Seized Property YES NO If yes, Describe

Damage to Property Local Court Bond $ Vehicle Impounded Injury License Posted in Lieu of Bond

Traffic Crash Death Appearance Certificate

Person in Active Military Service YES NO None

Appearance Date on or Before

Hearing Date (if Applicable ) on Contact Court Juvenile Traffic Misd. (Court Will Notify) Formal Hearing Required (Court Will Notify)

In the Court of

Misdemeanor - Defendant

Agency’s ORI Agency Name

PR

PR

000001

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Has Reasonable Cause To Believe That On or About Agency Use

Month Day Year At Approx AM

PM

Day of Week

YES NO

Name (First, Middle, Last)

Street

City State ZIP

State Driver’s License Number

Race Sex Date of Birth Height Weight Hair Eyes Scars or Marks

Type Vehicle Plate No. Year State Vehicle Description (Make, Model, Color)

Employed

The Person Named Above did in Violation of 1. State Law 2. Local Ordinance

3. Administrative Rule 4. Commission Order 5. Directors Order 6. Tribal

At or Near

Fel

YES NO

A

C/I Warn Conservation Fee Misd Fug Fel

YES NO

B

Seized Property YES NO If yes, Describe

Damage to Property Local Court Bond $ Vehicle Impounded Injury License Posted in Lieu of Bond

Traffic Crash Death Appearance Certificate

Person in Active Military Service YES NO None

Appearance Date on or Before

Hearing Date (if Applicable ) on Contact Court Juvenile Traffic Misd. (Court Will Notify) Formal Hearing Required (Court Will Notify)

In the Court of

Civil Infraction

Agency’s ORI Agency Name

PR

PR

000001

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