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Office of States Attorney

Baltimore County
401 Bosley Avenue
Towson, Atfary/and 21204
410-887-6600
Fax 410-887-6646
J,,fRS 800-735-2258
Scott D.
Statt 's
Date:
CITIZEN COMPLAINT BUREAU
Dear Complainant:
A District Court Commissioner has just issued a District Court charging document at your
request and on your oath. alleging the commission of a crime in Baltimore County, Maryland.
In order for this case to be properly evaluated and prepared, you !!l!!fil bring your copy of
the application for charges given to you by the Commissioner, and appear in person at the
Baltimore County State's Attorney's Office between the hours of 8:00 a.m. and 6:00 p.m. on one of
the three dates the Commissioner will assign you which are designated below. At that time you will
meet with a representative of the State' s Attorney's Office to determine the most appropriate way
to proceed with the case. Please bring with you any other documentation of the charges that you
may have in your possession.
Please be advised that if you have not reported this incident to the police, you may wish to
do so. Reporting the crime to the police documents the incident and affords the police the
opportunity to conduct any necessary investigation. This could develop potential witnesses and
evidence, which may enhance the prosecution of the case.
YOU MAY ONLY COME ON ONE OF THE THREE DATES LISTED BELOW.
IF YOU FAIL TO APPEAR FOR YOUR CONFERENCE ON ONE OF THE
DESIGNATED DAYS, THE STATE'S ATTORNEY'S OFFICE WILL DECLINE TO
PROSECUTE THE CASE.
The three dates on which you may appear are as follows:
5 /;v /t, , ; oR /1s
(Date) (Date)
SCOTT D. SHELLENBERGER
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STATE'S ATTORNEY FOR BALTIMORE COUNTY
Date
WHITE - COURT COPY YELLOW- VICTIM'S COPY ' PINK - STATE'S ATTORNEY'S COPY
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COURT OF MARYLAND FOR I
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Agmcy, sub-111eacy, llld l.D. # (Officer Only)
DEFENDANTS DESCRIPTION: Driver's License# _........._ ____ _.... ____ _
. ' Sex __ Race ../ Ht -' ---- Wt 6
Hair +-/-- Eyes ___ Complexion __ _
D.O.B I I I .; ID ------
APPLICATION FOR STATEMENT OF CHARGES Page I of
I, the undersigned, apply for statement of charges and a summons or warrant which may lead to the arrest of the
above named Defendant because on or about r / I I I I c. at -"" / '------"---'-...:.rr---'..:..;.;:__ ____ _
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theabovenamedDefendant
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(Continued on attached pages) (DC/CR IA)
I solemnly affirm under the penalties of perjury that the contents of this Application are true to the best of my knowledge,
information and belief.
Officer's Signa1urr
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I have read or had read to me and I understand the Notice on the back of this form.
</ /. /
_ _- -:::-----------------''--- -
Applicant's
Time: _______ M
Subscribed and sworn to before me this ___ /_() __ day of
Monih I ,.e..r-- _
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Judge/Commissioner ______
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Year
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I understand that a charging document will be and that I must appear for trial 0 on OM<
at when notified by the Clerk, at the Court location shown at the top of this form.
Time ;/?-;;;?" 1

0 I have advised applicant of shielding right. 0 Applicant declines shielding. :
0 I declined to issue a charging document because oflack of probable cause.
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DC/CR I (Rev. 12/2006) Print Dare (3/2010)
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APPLICATION FOR STATEMENT OF CHARGES (CONTINUED) Page __
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TRACKING NUMBER
DC/CR IA (Rev. 1/2002) Print Date (0 2013)
DISTRICT COURT OF FOR '/fAv/fi,c,._ ,r.(;
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APPLICATION FOR STATEMENT OF CHARGES (CONTINUED) Pagc ____J __ __ or __J ____ _
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Applo ant" 51gnaturc
TRACKING NUMBER
DC/CR lA ( Rev. 1/2002) Print Date (06/20 13)