The following form, or any other form that substantially complies with it, shall be used for offenses included on the schedule of offenses adopted pursuant to SDCL 16-2-21 and where a power of attorney option is provided:

1. (Defendant) No. _____________HP

   THE UNDERSIGNED PEACE OFFICER COMPLAINS AND STATES THAT

   ON OR ABOUT

   AT OR NEAR (LOCATION/MILE POST)

   AT TIME

   A.M.

   P.M.

   _________________

   ____________________________________

   ________

   WITHIN THE COUNTY AND STATE AFORESAID

   NAME

   HEIGHT

   SEX

   _____________________________

   ________

   _____

   ADDRESS

   WEIGHT

   _____________________________

   ________

   CITY

   STATE

   BIRTH DATE

   _____________________________

   ________

   ____________

   DRIVER'S LICENSE NO.

   STATE

   _____________________________

   ________

   DID UNLAWFULLY

   OPERATE

   _________

   PARK

   ______

   VEHICLE MAKE

   _______________

   BODY STYLE

   _____________

   STATE LICENSE NO.

   YEAR

   STATE

   FR______Y

   _____________________________

   ______

   _______

   ______N

   AND THEN AND THERE COMMIT THE FOLLOWING OFFENSE TO WIT:

   PETTY OFF _____

   MIS ______

   DESCRIBE VIOLATION:

   _________________________________________________

   CDL ____Y____N

   C Veh.____Y____N____E

   _________________________________________________

   Haz. Materials ____Y____N

   in violation of SDCL_________________________________

   _____Municipal

   SPEEDING

   _____Interstate

   _____Other

   ______M.P.H. IN

   ______M.P.H. ZONE

   OFFICER ISSUING SUMMONS

   NO.

   CITY

   COUNTY

   STATE

   ___________________________

   _____

   ______________

   _________

   _______

   POWER OF ATTORNEY

   ____________________________________ I hereby deposit with the Clerk of Courts of

   __________________________ County, South Dakota, as a cash appearance bond, the sum of

   $ ________________________ and understand that my initial appearance will be located in the

   city of ____________________________________.

   a m.

   on _____________________________________ at ________________________________ p.m.

   If I desire to contest this matter, I will appear at the date, time, and place for my initial appearance

   or contact the clerk of courts before that date and ask the clerk to reschedule the date for my

   initial appearance. If I do not appear or contact the clerk of courts within the time period, (or if

   after the court date is set, I fail to appear,) I hereby plead guilty to the charge, and direct the clerk

   to apply the money deposited as bond herewith to the payment of the fine and costs assessed

   against me.

   __________________ Cash taken by Officer - Officer signed

   I have read this document and have been given a copy.

   Signed

   ____________________________________________________________________________

   Defendant

   Date

   THE SIGNED COPY MUST BE ENCLOSED WITH MONEY IN THE ENVELOPE PROVIDED

POWER OF ATTORNEY

PCN ______________

State of South Dakota

In Circuit Court

Magistrate Division

County of_______________

____________Judicial Court

State of South Dakota (Plaintiff)

Vs

___________________________________

Source: 27 SDR 53, effective December 4, 2000.

General Authority: SDCL 23-1A-2.

Law Implemented: SDCL 23-1A-2 , 32-33-2.