STATEMENT OF FACTS
IN SUPPORT OF APPLICATION FOR CRIMINAL COMPLAINT
APPLICATION NO. (court use only)
PAGE ___ OF ___
Trial Court of Massachusetts District Court Department
The undersigned alleges the following as a full or partial statement of the factual basis for the offense(s) for which a criminal complaint is sought.
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COURT DIVISION
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(Use additional sheets if necessary) PRINTED NAME SIGNATURE I AM A: DATE SIGNED
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9 LAW ENFORCEMENT OFFICER 9 CIVILIAN COMPLAINANT OR WITNESS
ADDITIONAL FACTS FOUND BY CLERK-MAGISTRATE / ASST. CLERK / JUDGE BASED ON ORAL TESTIMONY
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REMARKS SIGNATURE OF CLERK-MAGISTRATE / ASST.CLERK / JUDGE DATE SIGNED
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DC-CR-34 (7/04)