|
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 |
