Department of Police Montgomery County, Maryland

MCP 140 Rev. 09/06

TRESPASS
Issue Date:

NOTIFICATION

FORM
Expiration Date:

Issue Time:

(one year from issue date)

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The purpose of this form is to notify That he/she is not permitted on the property/premises at

If you should enter the property/premises while this order is in effect, you shall be subject to immediate arrest by the Montgomery County Department of Police, or other authorized law enforcement agency, and charged with trespass under Criminal Law, Title 6, Subtitle 4, of the Annotated Code of Maryland. This order shall be in effect for one year from the above issue date. SUBJECT INFORMATION: / Name:
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STATEMENT OF FACTS (must be completed by Initiating

Officer when MCPD acts as property agent):

STATEMENT OF UNDERSTANDING: By my signature below, I acknowledge that I am authorized to initiate this letter of trespass notification as the property owner or agent. I further agree that should the above subject be arrested, I will appear in court to testify when notified to do so. Signature: (circle one)
Property Owner Agent

Printed Nanle:

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Subject's Signature:
(Subject acknowledges letter

of trespass

notification)

Initiating Officer:
Print Rank and Narne

ID#: Distribution:

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Function Code: 140 CALEA: None Proponent Unit: FSB Admin.

Original: Station Yellow: Officer Pink: Complainant Gold: Subject