ROXBURY MUNICIPAL COURT

State of New Jersey               )

                                                )        vs.               ____________________________________

County of New Jersey            )

________________________________, of full age, being duly sworn on his/her oath according to law deposes and says:

I offer the following facts to establish probable cause for the issuance of a summons for the defendant, charged with __________________________in complaint number __________________________.

Sworn to and subscribed before me this _________ day of ________________ 2005.

______________________________________                    _____________________________________

Administering Oath                                                                            Affiant’s Name