IN THE JUSTICE COURT OF COUNTY, STATE OF MONTANA

BEFORE , JUSTICE OF THE PEACE

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STATE OF MONTANA, * CAUSE NO.

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Plaintiff, * APPLICATION FOR

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vs. * COMPLAINT

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, *

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Defendant. *

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, being first duly sworn, deposes and says:

I am the victim of what I believe to be a criminal act, and wish to have the matter prosecuted. I understand that the consequences of my signing an application for a criminal complaint against the above-named defendant, may include the following:

1. The defendant may be arrested and placed in custody.

2. The arrest, if proved false, may result in a lawsuit against me.

3. This charge will be prosecuted even though I might later change my mind.

4. I, as well as other witnesses, will be required to appear in court and testify regardless of inconvenience.

The statement signed by me this date contains a true account of the offense committed by the defendant. I request that the defendant be apprehended and brought before the Court to be dealt with according to law.

DATED this day of , 19 .

Complainant

SUBSCRIBED AND SWORN to before me this day of

, 19 .

(SEAL) Notary Public for the State of Montana

Residing at: My Commission expires: