PLAINTIFF:

. D State oflowa
9:ounty of:

./ L;UMPU\INI D NON-RES
li.
foWA UNIFOR1>1 CITATION AND COMPLAINT D HIS
. IOWA CITY POLICE DEPARTMENT ARMED D
INC# tZ6,<I,----------,
JOHNSON lie N2 221642'1.
IOWA CIT'f.. ., . .. \oj' .

In the Court at 417 S. CLINTON STREET, JOHNSON COUNTY COURTHOUSE
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Defendant, Lasl Firsl Middle
Address Zzt, vj- \
Cily 4 1;- y. Slatc;t;f= Zip .
SS/DLff Statc ;;;:::;1= Co. # _"-" _
DL Cly!; t DL ID Viewed?
DOn "" Elhn. V (pc;?S
WIlJIIIAlU II/N/U /.
The undersigned states that on or about k?? / le / l D PM
defendant did unlawfully: Mo. Day Yr.
..
Operate Molor Vehicle/l3oat (describe) ________________ . ___ _
CDL Reg? YesD NoD Pass End. Reg'! YesD NoD lIuz1vlat End Reg. YesD NoD
Reg. ti------------:=-_:-:--Jilill,e ________ year ____ _
Upon a public highway ut ____ F.:1.-t-' ::> _________ --'-____ _
Located in the county and state aforesaid und did then and there commit the following offense:'
DTrnflic D Navigation D Snowmobile/ATV DFish-Game DParks DTobacco
,kcheduled Vio/Fine $ .X2 Po D Road Construction Zone
f I 5 . DNon-Seheduled Violation
Surcharge S Ie 0 0 (} 0 Court Appearance Required (805.10)
I 0 . Reason:
01'.1. 0 P.D. (S I 000) Accidenl Do Court Cosls
. 0 Fatal Accident
$:: L/ it 5 0 Civil Damage Assessment
i ,
Not Total Fine/Costs
Viol111ion-:1rV V 1(/'1> tIlL z1
Write Speed In ZOlle-Sec. # . IA C9j;lc
DATA CODE J Fed/Adm. Code Loenl
In
Tliis
Space
I ccrtily ullllelpen:lllY OfPCljlllY :lIld liursu:lnt to lhe laws or lhe State of lown lhatthe
preCCding8true allli COITCCI. . . 4t:-
Dalcd '1 / r IC' fA/' 15
1\10. 1J(,y , r. No.
Court Date: If you 111 list appear in COllrt or if you choose to nppcar to nnslI'cr a c11nrge
whic 1 docs not reguire nn appearance, rcp 10 !Jlp-:B0ve namcd courl on:
/ / '- al,(Y' .' 1\1 DPM
()a Yr.
Providing Illise informalion is a violation orScction 719.3 of the Code of
Iowa and is punishable as an aggravated l11isdcmeanor.
My signature below is not a plea of guilty, but acknowledges all of the following:
I. I hereby swear and aflinnlhallhe informal ion prodded by me onlhis cilalion is Irlle IInder pcnally
of providing Ihlse infonnniion.
2. I promise 10 appear in snid court III said lime nnd place, or I will comply wilh Ihe provision on Ihe
lOp of the reverse side of Ihe eilalion. 1
The Ibllowing applies 10 silllple llIisdemcanors only: f 012..5" eJ 13.::::5
3. I hcrcby give Illy IInsccllrcd appcanll1ce bond inlhe 1I1l101llii dollars allli cnl Illy
appearnnce. I agrce Ihal if I fi,il 10 appcar in person or by counsel to'dcfell< againsl Ihe olTcnse charged
in Ihis cilalion, Ihe courl is .aulhorizcd 10 enler a conviclion and render j ,uglllcnl againsl llIe for Ihe
aillouni of Illy appcaranee b ,. ,llisli,elion of Ihe pen' Ily and sur 'harge .Ius courl cosls.
IOWA CITY IA 17-5 prinled by G.A. Thompson Co . Dallas, Tx 75204 1 (800) 527-0340 www.galhompson.com
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