MISDEMEANOR SUMMONS

AND COMPLAINT F{S Sq*$i":.

The undersigned officer complains that:
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STATE
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DATE OF BIRTH RACE SEX
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HEIGHT WEIGHT

LICENSE AND MOTOR VEHICLE

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REGISTRATION NO. STATE IMAKE/MOIJEUS IYLE , YEAR ICOLOR
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OWNED BY (LadtiFtlsi Middl$
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AlrlrRESS (A/o., streela,td STATE
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)treet g Highway: lflntersection. spec{y)
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did'eomrnit ttre f6tlowing Ifl SIIEMEANORS/V|OI-ATION{g}

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ACTUAL SPEED PosF"lD{rr ROAD COND. TRAFFIC VISIBILIry AREA
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BOND AMOUNT ICC/DOT NO. (Circle one) COMMERCIAUHAZARD, I\,4AT,

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promise to appear in couft as scheduled above and to comply with the
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conditions of release stated an the back of this form. I have read/had read
to me the notice on the back of this form and I understand it.
-qu ru r.u. SIGNATURE (Person receivingthis complaint)

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CONNECTICUT SUPERIOR COURT
JD-CR-1 Rev.3-07

DEFENDANT'S COPY - SEE INSTRUCTIONS ON BACK