charged in this citation, the court is authorized to enter a conviction and render judgment against me for the amount of my appearance bond in satisfaction of the penalty and surcharge plus court cost.

You hereby are given notice that within a reasonable time but no later than the date scheduled for yourinitial appearance a citation/complaint sworn under oath will be filed with the district court clerk of thecounty in which this citation was issued.

Speed

IA Code:

State of Iowa

this

Road Work Zone

Weight

Agency

City

Zone

Court Costs

1. I hereby swear and affirm that the information provided by me on this citation is true under penalty of providing false information.

My signature below is not a plea of guilty, but acknowledges all of the following:

PLAINTIFF

4. I hereby give my unsecured appearance bond in the amount of

ICIS Sec #:

Subscribed and sworn to me by

at

Fed/Adm Code:

NOTICE: Providing false identification information is a violation of Section 719.1A ofthe Code of Iowa and is punishable as a simple misdemeanor.

Law Enforcement Agency -

Violation

DL State

In the Court at

Located in the county and state aforesaid and did then and there commit the following offense:

Fatal Accident

DL Rest.

Dated

Court Date: If you must appear in court or if you choose to appear to answer to a charge which does not

day of

Zip Code

Form 420001E 1/07

DOB

Local Ord.

Height

require an appearance, report to the above named court on:

Court Appearance Required (805.10)

VS.

Name

DL/State IDViewed?

Race

Sex

The following applies to simple misdemeanors only:

The undersigned states that on or about

Sec #:

Upon a public highway at

CDLReq?

Year

dollars and enter my written appearance. I agree that if I fail to appear in person or by counsel to defend against the offense

DL End.

DL#

Address

IOWA UNIFORM CITATION AND COMPLAINT

I swear that the foregoing complaint is true and correct. , Iowa

ICC# Lic. Plate #/REG

I.D. No.

Reference #:

Signature ofDefendant

City of:

Dispatch /Case #:

20

US DOT#

DL Class

State

2. I promise to appear in said court at said time and place. I understand that a person who willfully fails to appear in court as specified by this citation may be subject to arrest and/or loss of driving privileges.

First

defendant did unlawfully: Operate Motor Vehicle/Boat

State

Scheduled Violation/Fine

Suffix

Criminal SurchargeSerious P.I.

in

Notary/other

Reason:

3. If a court appearance is not required, I may enter a plea of guilty prior to the designated appearance date by delivery in person, or by agent, or by mail to the court specified by this citation.

Civil Damage Assessment Other

County of:

Officer'sSignature

Total Fine/Costs

HazMat End Req?

Officer'sSignature

Non-scheduled Violation

X

ICIS Ord.

at

Defendant, Last

at

COMPLAINT

Pass EndReq?

Co. Enf. Surcharge

Middle

Notary/otherSignature

Dated

T01 T405 150323 115539 3

*+T01T4051503231155393+*

Citation #:

MOTOR VEHICLE ENFORCEMENT

SAC - 81

SAC COUNTY COURTHOUSE 100 NW STATE STREET SUITE 12 SAC CITY IA 50583

S 200 155 261 151SCHOCH DUANE FREDERICK 2/27/1945YES

W NEthnicity48867-4317OWOSSO MI817 S SHIAWASSEE ST

5' 04"MI 300 LBSNONE MALEA NONE

03/23/2015 11:00 AM 2000 WHI FORD -FORD

TR-ST

2016 YES NO NOMICPR526900306396 889139

US 71/KARR AVE

$50.00

$17.50391.45B

N/A13MEDICAL CARD EXPIRED 3-11-15

$60.00

321.449 321.449-B$127.50

T405

03/23/2015

03/23/2015

8:30 AM04/13/2015

$161.25

EARLY - 2200MCFARLAND, TIMOTHY

MARCH, 201525

OTHERMOTOR VEHICLE ENFORCEMENT

NOT GUILTY

Driver's LicenseRecommendation

OTHER DISPOSITION

Other

Susp.

Yr.

BAIL CASH DEPOSIT

DATE: Continued to:

Incarceration in

VERDICT

WARRANT ISSUED

Iowa

DISMISSED

TESTIMONY - JUDGE'S NOTES: (Other Orders)

Revo

Mo.

Signature, person giving bail

TO THE COURT: The following are witnesses who can give testimony relating to the facts of this alleged violation. Please subpoena prosecuting witness:

COST $

ABSTRACT OF COURT RECORD

Address

JURY TRIAL

Days:

DOCKET NO.

REASON

CASE NO.

School

CASE NO.

STATE:

Days

Name

FORFEIT BOND

The court Therefore Enters in Following Order This Date

REASON

Phone

PLEA

LICENSE NO.

NOT GUILTY

Citation #:

GUILTY

Signature, person taking bailDate

DATE:

NO JURY TRIAL orPROCEEDING

GUILTY

DATE:

None

Day

COURT NO.

FINED $ SURCHARGE $ Continued to:

T01 T405 150323 115539 3

FILED 03/25/2015 10:30AMCLERK DISTRICT COURTSAC COUNTY IOWA

charged in this citation, the court is authorized to enter a conviction and render judgment against me for the amount of my appearance bond in satisfaction of the penalty and surcharge plus court cost.

You hereby are given notice that within a reasonable time but no later than the date scheduled for yourinitial appearance a citation/complaint sworn under oath will be filed with the district court clerk of thecounty in which this citation was issued.

Speed

IA Code:

State of Iowa

this

Road Work Zone

Weight

Agency

City

Zone

Court Costs

1. I hereby swear and affirm that the information provided by me on this citation is true under penalty of providing false information.

My signature below is not a plea of guilty, but acknowledges all of the following:

PLAINTIFF

4. I hereby give my unsecured appearance bond in the amount of

ICIS Sec #:

Subscribed and sworn to me by

at

Fed/Adm Code:

NOTICE: Providing false identification information is a violation of Section 719.1A ofthe Code of Iowa and is punishable as a simple misdemeanor.

Law Enforcement Agency -

Violation

DL State

In the Court at

Located in the county and state aforesaid and did then and there commit the following offense:

Fatal Accident

DL Rest.

Dated

Court Date: If you must appear in court or if you choose to appear to answer to a charge which does not

day of

Zip Code

Form 420001E 1/07

DOB

Local Ord.

Height

require an appearance, report to the above named court on:

Court Appearance Required (805.10)

VS.

Name

DL/State IDViewed?

Race

Sex

The following applies to simple misdemeanors only:

The undersigned states that on or about

Sec #:

Upon a public highway at

CDLReq?

Year

dollars and enter my written appearance. I agree that if I fail to appear in person or by counsel to defend against the offense

DL End.

DL#

Address

IOWA UNIFORM CITATION AND COMPLAINT

I swear that the foregoing complaint is true and correct. , Iowa

ICC# Lic. Plate #/REG

I.D. No.

Reference #:

Signature ofDefendant

City of:

Dispatch /Case #:

20

US DOT#

DL Class

State

2. I promise to appear in said court at said time and place. I understand that a person who willfully fails to appear in court as specified by this citation may be subject to arrest and/or loss of driving privileges.

First

defendant did unlawfully: Operate Motor Vehicle/Boat

State

Scheduled Violation/Fine

Suffix

Criminal SurchargeSerious P.I.

in

Notary/other

Reason:

3. If a court appearance is not required, I may enter a plea of guilty prior to the designated appearance date by delivery in person, or by agent, or by mail to the court specified by this citation.

Civil Damage Assessment Other

County of:

Officer'sSignature

Total Fine/Costs

HazMat End Req?

Officer'sSignature

Non-scheduled Violation

X

ICIS Ord.

at

Defendant, Last

at

COMPLAINT

Pass EndReq?

Co. Enf. Surcharge

Middle

Notary/otherSignature

Dated

T01 T405 150323 115635 4

*+T01T4051503231156354+*

Citation #:

MOTOR VEHICLE ENFORCEMENT

SAC - 81

SAC COUNTY COURTHOUSE 100 NW STATE STREET SUITE 12 SAC CITY IA 50583

S 200 155 261 151SCHOCH DUANE FREDERICK 2/27/1945YES

W NEthnicity48867-4317OWOSSO MI817 S SHIAWASSEE ST

5' 04"MI 300 LBSNONE MALEA NONE

03/23/2015 11:00 AM 2000 WHI FORD -FORD

TR-ST

2016 YES NO NOMICPR526900306396 889139

US 71/KARR AVE

$50.00

$17.50393.95A

N/A13DISCHARGED FIRE EXTINGUISHER

$60.00

321.449 321.449-A$127.50

T405

03/23/2015

03/23/2015

8:30 AM04/13/2015

$161.25

EARLY - 2200MCFARLAND, TIMOTHY

MARCH, 201525

OTHERMOTOR VEHICLE ENFORCEMENT

NOT GUILTY

Driver's LicenseRecommendation

OTHER DISPOSITION

Other

Susp.

Yr.

BAIL CASH DEPOSIT

DATE: Continued to:

Incarceration in

VERDICT

WARRANT ISSUED

Iowa

DISMISSED

TESTIMONY - JUDGE'S NOTES: (Other Orders)

Revo

Mo.

Signature, person giving bail

TO THE COURT: The following are witnesses who can give testimony relating to the facts of this alleged violation. Please subpoena prosecuting witness:

COST $

ABSTRACT OF COURT RECORD

Address

JURY TRIAL

Days:

DOCKET NO.

REASON

CASE NO.

School

CASE NO.

STATE:

Days

Name

FORFEIT BOND

The court Therefore Enters in Following Order This Date

REASON

Phone

PLEA

LICENSE NO.

NOT GUILTY

Citation #:

GUILTY

Signature, person taking bailDate

DATE:

NO JURY TRIAL orPROCEEDING

GUILTY

DATE:

None

Day

COURT NO.

FINED $ SURCHARGE $ Continued to:

T01 T405 150323 115635 4

FILED 03/25/2015 10:30AMCLERK DISTRICT COURTSAC COUNTY IOWA

charged in this citation, the court is authorized to enter a conviction and render judgment against me for the amount of my appearance bond in satisfaction of the penalty and surcharge plus court cost.

You hereby are given notice that within a reasonable time but no later than the date scheduled for yourinitial appearance a citation/complaint sworn under oath will be filed with the district court clerk of thecounty in which this citation was issued.

Speed

IA Code:

State of Iowa

this

Road Work Zone

Weight

Agency

City

Zone

Court Costs

1. I hereby swear and affirm that the information provided by me on this citation is true under penalty of providing false information.

My signature below is not a plea of guilty, but acknowledges all of the following:

PLAINTIFF

4. I hereby give my unsecured appearance bond in the amount of

ICIS Sec #:

Subscribed and sworn to me by

at

Fed/Adm Code:

NOTICE: Providing false identification information is a violation of Section 719.1A ofthe Code of Iowa and is punishable as a simple misdemeanor.

Law Enforcement Agency -

Violation

DL State

In the Court at

Located in the county and state aforesaid and did then and there commit the following offense:

Fatal Accident

DL Rest.

Dated

Court Date: If you must appear in court or if you choose to appear to answer to a charge which does not

day of

Zip Code

Form 420001E 1/07

DOB

Local Ord.

Height

require an appearance, report to the above named court on:

Court Appearance Required (805.10)

VS.

Name

DL/State IDViewed?

Race

Sex

The following applies to simple misdemeanors only:

The undersigned states that on or about

Sec #:

Upon a public highway at

CDLReq?

Year

dollars and enter my written appearance. I agree that if I fail to appear in person or by counsel to defend against the offense

DL End.

DL#

Address

IOWA UNIFORM CITATION AND COMPLAINT

I swear that the foregoing complaint is true and correct. , Iowa

ICC# Lic. Plate #/REG

I.D. No.

Reference #:

Signature ofDefendant

City of:

Dispatch /Case #:

20

US DOT#

DL Class

State

2. I promise to appear in said court at said time and place. I understand that a person who willfully fails to appear in court as specified by this citation may be subject to arrest and/or loss of driving privileges.

First

defendant did unlawfully: Operate Motor Vehicle/Boat

State

Scheduled Violation/Fine

Suffix

Criminal SurchargeSerious P.I.

in

Notary/other

Reason:

3. If a court appearance is not required, I may enter a plea of guilty prior to the designated appearance date by delivery in person, or by agent, or by mail to the court specified by this citation.

Civil Damage Assessment Other

County of:

Officer'sSignature

Total Fine/Costs

HazMat End Req?

Officer'sSignature

Non-scheduled Violation

X

ICIS Ord.

at

Defendant, Last

at

COMPLAINT

Pass EndReq?

Co. Enf. Surcharge

Middle

Notary/otherSignature

Dated

S81 BACK 150325 104649 0

*+S81BACK1503251046490+*

Citation #:

SAC COUNTY SHERIFF'S OFFICE

SAC - 81

SAC COUNTY COURTHOUSE 100 NW STATE STREET SUITE 12 SAC CITY IA 50583

T960273672115CARMONA GERMAN AUGUSTO 11/3/1957YES

W UEthnicity55437BLOOMINGTON MN10273 SCARBOROUGH RD

MN B MALED NONE

03/25/2015 10:46 AM 2014 WHI HONDA -HOND

CIVIC 4D

2015 NOMN669MWG

US 71/UNION AVE

5565$40.00

$14.00

$5.0015SPEEDING 55 OR < (6 THRU 10 OVER)

$60.00

321.285 321.285-B$119.00

81-5

03/25/2015

03/25/2015

8:30 AM04/20/2015

$148.50

SAC CITY - 6717CUDABACK, TORY

MARCH, 201525

NOTARYSAC COUNTY SHERIFF'S OFFICE

NOT GUILTY

Driver's LicenseRecommendation

OTHER DISPOSITION

Other

Susp.

Yr.

BAIL CASH DEPOSIT

DATE: Continued to:

Incarceration in

VERDICT

WARRANT ISSUED

Iowa

DISMISSED

TESTIMONY - JUDGE'S NOTES: (Other Orders)

Revo

Mo.

Signature, person giving bail

TO THE COURT: The following are witnesses who can give testimony relating to the facts of this alleged violation. Please subpoena prosecuting witness:

COST $

ABSTRACT OF COURT RECORD

Address

JURY TRIAL

Days:

DOCKET NO.

REASON

CASE NO.

School

CASE NO.

STATE:

Days

Name

FORFEIT BOND

The court Therefore Enters in Following Order This Date

REASON

Phone

PLEA

LICENSE NO.

NOT GUILTY

Citation #:

GUILTY

Signature, person taking bailDate

DATE:

NO JURY TRIAL orPROCEEDING

GUILTY

DATE:

None

Day

COURT NO.

FINED $ SURCHARGE $ Continued to:

S81 BACK 150325 104649 0

FILED 03/25/2015 11:22AMCLERK DISTRICT COURTSAC COUNTY IOWA

charged in this citation, the court is authorized to enter a conviction and render judgment against me for the amount of my appearance bond in satisfaction of the penalty and surcharge plus court cost.

You hereby are given notice that within a reasonable time but no later than the date scheduled for yourinitial appearance a citation/complaint sworn under oath will be filed with the district court clerk of thecounty in which this citation was issued.

Speed

IA Code:

State of Iowa

this

Road Work Zone

Weight

Agency

City

Zone

Court Costs

1. I hereby swear and affirm that the information provided by me on this citation is true under penalty of providing false information.

My signature below is not a plea of guilty, but acknowledges all of the following:

PLAINTIFF

4. I hereby give my unsecured appearance bond in the amount of

ICIS Sec #:

Subscribed and sworn to me by

at

Fed/Adm Code:

NOTICE: Providing false identification information is a violation of Section 719.1A ofthe Code of Iowa and is punishable as a simple misdemeanor.

Law Enforcement Agency -

Violation

DL State

In the Court at

Located in the county and state aforesaid and did then and there commit the following offense:

Fatal Accident

DL Rest.

Dated

Court Date: If you must appear in court or if you choose to appear to answer to a charge which does not

day of

Zip Code

Form 420001E 1/07

DOB

Local Ord.

Height

require an appearance, report to the above named court on:

Court Appearance Required (805.10)

VS.

Name

DL/State IDViewed?

Race

Sex

The following applies to simple misdemeanors only:

The undersigned states that on or about

Sec #:

Upon a public highway at

CDLReq?

Year

dollars and enter my written appearance. I agree that if I fail to appear in person or by counsel to defend against the offense

DL End.

DL#

Address

IOWA UNIFORM CITATION AND COMPLAINT

I swear that the foregoing complaint is true and correct. , Iowa

ICC# Lic. Plate #/REG

I.D. No.

Reference #:

Signature ofDefendant

City of:

Dispatch /Case #:

20

US DOT#

DL Class

State

2. I promise to appear in said court at said time and place. I understand that a person who willfully fails to appear in court as specified by this citation may be subject to arrest and/or loss of driving privileges.

First

defendant did unlawfully: Operate Motor Vehicle/Boat

State

Scheduled Violation/Fine

Suffix

Criminal SurchargeSerious P.I.

in

Notary/other

Reason:

3. If a court appearance is not required, I may enter a plea of guilty prior to the designated appearance date by delivery in person, or by agent, or by mail to the court specified by this citation.

Civil Damage Assessment Other

County of:

Officer'sSignature

Total Fine/Costs

HazMat End Req?

Officer'sSignature

Non-scheduled Violation

X

ICIS Ord.

at

Defendant, Last

at

COMPLAINT

Pass EndReq?

Co. Enf. Surcharge

Middle

Notary/otherSignature

Dated

T01 T142 150323 105622 7

*+T01T1421503231056227+*

Citation #:

MOTOR VEHICLE ENFORCEMENT

SAC - 81

SAC COUNTY COURTHOUSE 100 NW STATE STREET SUITE 12 SAC CITY IA 50583

364AE8238HIBBING RICHARD DUANE 8/29/1955YES

W NEthnicity50595-0000WEBSTER CITY IA1514 WILLSON AVE

5' 10"IA 195 LBSJ MALEA LTX

03/23/2015 10:50 AM 2007 MAR FREIGHTLINER - F

TT/ST

2015 YES NO YESIASG206300606058 290229

US 71/KARR AVE AND D015/190TH ST

$50.00

$17.50392.16

N/A13FAILING TO USE SEAT BELT WHILE OPERATING CMV

$60.00

321.445 321.445$127.50

T142

03/23/2015

03/23/2015

8:30 AM04/06/2015

$161.25

FORT DODGE - 2690PEREZ, WILLIAM

MARCH, 201525

OTHERMOTOR VEHICLE ENFORCEMENT

NOT GUILTY

Driver's LicenseRecommendation

OTHER DISPOSITION

Other

Susp.

Yr.

BAIL CASH DEPOSIT

DATE: Continued to:

Incarceration in

VERDICT

WARRANT ISSUED

Iowa

DISMISSED

TESTIMONY - JUDGE'S NOTES: (Other Orders)

Revo

Mo.

Signature, person giving bail

TO THE COURT: The following are witnesses who can give testimony relating to the facts of this alleged violation. Please subpoena prosecuting witness:

COST $

ABSTRACT OF COURT RECORD

Address

JURY TRIAL

Days:

DOCKET NO.

REASON

CASE NO.

School

CASE NO.

STATE:

Days

Name

FORFEIT BOND

The court Therefore Enters in Following Order This Date

REASON

Phone

PLEA

LICENSE NO.

NOT GUILTY

Citation #:

GUILTY

Signature, person taking bailDate

DATE:

NO JURY TRIAL orPROCEEDING

GUILTY

DATE:

None

Day

COURT NO.

FINED $ SURCHARGE $ Continued to:

T01 T142 150323 105622 7

FILED 03/25/2015 02:30PMCLERK DISTRICT COURTSAC COUNTY IOWA

charged in this citation, the court is authorized to enter a conviction and render judgment against me for the amount of my appearance bond in satisfaction of the penalty and surcharge plus court cost.

You hereby are given notice that within a reasonable time but no later than the date scheduled for yourinitial appearance a citation/complaint sworn under oath will be filed with the district court clerk of thecounty in which this citation was issued.

Speed

IA Code:

State of Iowa

this

Road Work Zone

Weight

Agency

City

Zone

Court Costs

1. I hereby swear and affirm that the information provided by me on this citation is true under penalty of providing false information.

My signature below is not a plea of guilty, but acknowledges all of the following:

PLAINTIFF

4. I hereby give my unsecured appearance bond in the amount of

ICIS Sec #:

Subscribed and sworn to me by

at

Fed/Adm Code:

NOTICE: Providing false identification information is a violation of Section 719.1A ofthe Code of Iowa and is punishable as a simple misdemeanor.

Law Enforcement Agency -

Violation

DL State

In the Court at

Located in the county and state aforesaid and did then and there commit the following offense:

Fatal Accident

DL Rest.

Dated

Court Date: If you must appear in court or if you choose to appear to answer to a charge which does not

day of

Zip Code

Form 420001E 1/07

DOB

Local Ord.

Height

require an appearance, report to the above named court on:

Court Appearance Required (805.10)

VS.

Name

DL/State IDViewed?

Race

Sex

The following applies to simple misdemeanors only:

The undersigned states that on or about

Sec #:

Upon a public highway at

CDLReq?

Year

dollars and enter my written appearance. I agree that if I fail to appear in person or by counsel to defend against the offense

DL End.

DL#

Address

IOWA UNIFORM CITATION AND COMPLAINT

I swear that the foregoing complaint is true and correct. , Iowa

ICC# Lic. Plate #/REG

I.D. No.

Reference #:

Signature ofDefendant

City of:

Dispatch /Case #:

20

US DOT#

DL Class

State

2. I promise to appear in said court at said time and place. I understand that a person who willfully fails to appear in court as specified by this citation may be subject to arrest and/or loss of driving privileges.

First

defendant did unlawfully: Operate Motor Vehicle/Boat

State

Scheduled Violation/Fine

Suffix

Criminal SurchargeSerious P.I.

in

Notary/other

Reason:

3. If a court appearance is not required, I may enter a plea of guilty prior to the designated appearance date by delivery in person, or by agent, or by mail to the court specified by this citation.

Civil Damage Assessment Other

County of:

Officer'sSignature

Total Fine/Costs

HazMat End Req?

Officer'sSignature

Non-scheduled Violation

X

ICIS Ord.

at

Defendant, Last

at

COMPLAINT

Pass EndReq?

Co. Enf. Surcharge

Middle

Notary/otherSignature

Dated

T01 T142 150323 121842 9

*+T01T1421503231218429+*

Citation #:

MOTOR VEHICLE ENFORCEMENT

SAC - 81

SAC COUNTY COURTHOUSE 100 NW STATE STREET SUITE 12 SAC CITY IA 50583

160BB7569RUBNER ROBERT JAY 7/7/1973YES

W NEthnicity50674-0000SUMNER IA813 E 1ST ST

6' 00"IA 230 LBSBL MALEA NONE

03/23/2015 11:50 AM 2008 BLK DODGE -DODG

R35 TR/ST

2015 YES NO NOIAAVJ75501739187 406408

US 71/KARR AVE

$50.00

$17.50395.8F1

N/A13LOG BOOK NOT CURRENT DRIVER DID NOT START LOG BOOK FOR TODAY

$60.00

321.449 321.449-C$127.50

T142

03/23/2015

03/23/2015

8:30 AM04/06/2015

$161.25

FORT DODGE - 2690PEREZ, WILLIAM

MARCH, 201525

OTHERMOTOR VEHICLE ENFORCEMENT

NOT GUILTY

Driver's LicenseRecommendation

OTHER DISPOSITION

Other

Susp.

Yr.

BAIL CASH DEPOSIT

DATE: Continued to:

Incarceration in

VERDICT

WARRANT ISSUED

Iowa

DISMISSED

TESTIMONY - JUDGE'S NOTES: (Other Orders)

Revo

Mo.

Signature, person giving bail

TO THE COURT: The following are witnesses who can give testimony relating to the facts of this alleged violation. Please subpoena prosecuting witness:

COST $

ABSTRACT OF COURT RECORD

Address

JURY TRIAL

Days:

DOCKET NO.

REASON

CASE NO.

School

CASE NO.

STATE:

Days

Name

FORFEIT BOND

The court Therefore Enters in Following Order This Date

REASON

Phone

PLEA

LICENSE NO.

NOT GUILTY

Citation #:

GUILTY

Signature, person taking bailDate

DATE:

NO JURY TRIAL orPROCEEDING

GUILTY

DATE:

None

Day

COURT NO.

FINED $ SURCHARGE $ Continued to:

T01 T142 150323 121842 9

FILED 03/25/2015 02:30PMCLERK DISTRICT COURTSAC COUNTY IOWA

charged in this citation, the court is authorized to enter a conviction and render judgment against me for the amount of my appearance bond in satisfaction of the penalty and surcharge plus court cost.

You hereby are given notice that within a reasonable time but no later than the date scheduled for yourinitial appearance a citation/complaint sworn under oath will be filed with the district court clerk of thecounty in which this citation was issued.

Speed

IA Code:

State of Iowa

this

Road Work Zone

Weight

Agency

City

Zone

Court Costs

1. I hereby swear and affirm that the information provided by me on this citation is true under penalty of providing false information.

My signature below is not a plea of guilty, but acknowledges all of the following:

PLAINTIFF

4. I hereby give my unsecured appearance bond in the amount of

ICIS Sec #:

Subscribed and sworn to me by

at

Fed/Adm Code:

NOTICE: Providing false identification information is a violation of Section 719.1A ofthe Code of Iowa and is punishable as a simple misdemeanor.

Law Enforcement Agency -

Violation

DL State

In the Court at

Located in the county and state aforesaid and did then and there commit the following offense:

Fatal Accident

DL Rest.

Dated

Court Date: If you must appear in court or if you choose to appear to answer to a charge which does not

day of

Zip Code

Form 420001E 1/07

DOB

Local Ord.

Height

require an appearance, report to the above named court on:

Court Appearance Required (805.10)

VS.

Name

DL/State IDViewed?

Race

Sex

The following applies to simple misdemeanors only:

The undersigned states that on or about

Sec #:

Upon a public highway at

CDLReq?

Year

dollars and enter my written appearance. I agree that if I fail to appear in person or by counsel to defend against the offense

DL End.

DL#

Address

IOWA UNIFORM CITATION AND COMPLAINT

I swear that the foregoing complaint is true and correct. , Iowa

ICC# Lic. Plate #/REG

I.D. No.

Reference #:

Signature ofDefendant

City of:

Dispatch /Case #:

20

US DOT#

DL Class

State

2. I promise to appear in said court at said time and place. I understand that a person who willfully fails to appear in court as specified by this citation may be subject to arrest and/or loss of driving privileges.

First

defendant did unlawfully: Operate Motor Vehicle/Boat

State

Scheduled Violation/Fine

Suffix

Criminal SurchargeSerious P.I.

in

Notary/other

Reason:

3. If a court appearance is not required, I may enter a plea of guilty prior to the designated appearance date by delivery in person, or by agent, or by mail to the court specified by this citation.

Civil Damage Assessment Other

County of:

Officer'sSignature

Total Fine/Costs

HazMat End Req?

Officer'sSignature

Non-scheduled Violation

X

ICIS Ord.

at

Defendant, Last

at

COMPLAINT

Pass EndReq?

Co. Enf. Surcharge

Middle

Notary/otherSignature

Dated

T01 T142 150323 121851 0

*+T01T1421503231218510+*

Citation #:

MOTOR VEHICLE ENFORCEMENT

SAC - 81

SAC COUNTY COURTHOUSE 100 NW STATE STREET SUITE 12 SAC CITY IA 50583

160BB7569RUBNER ROBERT JAY 7/7/1973YES

W NEthnicity50674-0000SUMNER IA813 E 1ST ST

6' 00"IA 230 LBSBL MALEA NONE

03/23/2015 11:50 AM 2008 BLK DODGE -DODG

R35 TR/ST

2015 YES NO NOIAAVJ75501739187 406408

US 71/KARR AVE

$50.00

$17.50393.75B

N/A13AXLE #1 LEFT & RIGHT TIRES TREAD DEPTH LESS THAN 2/32 OF INCH

$60.00

321.449 321.449-A$127.50

T142

03/23/2015

03/23/2015

8:30 AM04/06/2015

$161.25

FORT DODGE - 2690PEREZ, WILLIAM

MARCH, 201525

OTHERMOTOR VEHICLE ENFORCEMENT

NOT GUILTY

Driver's LicenseRecommendation

OTHER DISPOSITION

Other

Susp.

Yr.

BAIL CASH DEPOSIT

DATE: Continued to:

Incarceration in

VERDICT

WARRANT ISSUED

Iowa

DISMISSED

TESTIMONY - JUDGE'S NOTES: (Other Orders)

Revo

Mo.

Signature, person giving bail

TO THE COURT: The following are witnesses who can give testimony relating to the facts of this alleged violation. Please subpoena prosecuting witness:

COST $

ABSTRACT OF COURT RECORD

Address

JURY TRIAL

Days:

DOCKET NO.

REASON

CASE NO.

School

CASE NO.

STATE:

Days

Name

FORFEIT BOND

The court Therefore Enters in Following Order This Date

REASON

Phone

PLEA

LICENSE NO.

NOT GUILTY

Citation #:

GUILTY

Signature, person taking bailDate

DATE:

NO JURY TRIAL orPROCEEDING

GUILTY

DATE:

None

Day

COURT NO.

FINED $ SURCHARGE $ Continued to:

T01 T142 150323 121851 0

FILED 03/25/2015 02:30PMCLERK DISTRICT COURTSAC COUNTY IOWA