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PROBABLE CAUSE STATEMENT FORM Date Report Number I Name and identify law enforcement officer or person having information as to probable cause. knowing that false statements on this form are punishable by law state that the facts contained herein are true. 1. I have probable cause to believe that on at in Address Clay County Missouri City Name of Offender s committed one or more criminal offense s. 1. I have probable cause to believe that on at in Address Clay County Missouri City Name of Offender s committed one or more criminal offense s. Description of Identity Insert the criminal offenses s that you have probable cause to believe that his offender committed here. Delete this instruction in this bracket before you submit this form. 2. The facts supporting this belief are as follows Insert the facts here as to why the law enforcement officer signing this probably cause statement has probably cause to believe this offender committed the listed offense s here. PROBABLE CAUSE STATEMENT FORM Date Report Number I Name and identify law enforcement officer or person having information as to probable cause. knowing that false statements on this form are punishable by law state that the facts contained herein are true. 1. I have probable cause to believe that on at in Address Clay County Missouri City Name of Offender s committed one or more criminal offense s. Description of Identity Insert the criminal offenses s that you have probable cause to believe that his offender committed here. Delete this instruction in this bracket before you submit this form* 2. The facts supporting this belief are as follows Insert the facts here as to why the law enforcement officer signing this probably cause statement has probably cause to believe this offender committed the listed offense s here. Delete this instruction in this bracket before you submit this form* 3. I believe that the defendant will not appear in court in response to a criminal summons because Number 3 is only required if you are requesting a warrant in a misdemeanor case. It is not required and must be deleted if this is a felony if this is a misdemeanor and you are not requesting a warrant or if you are requesting a warrant but you have no facts to support this statement An example for number 3 is There is an outstanding warrant for failure to appear Page 1 of 2 Printed Name Signature. PROBABLE CAUSE STATEMENT FORM Date Report Number I Name and identify law enforcement officer or person having information as to probable cause. knowing that false statements on this form are punishable by law state that the facts contained herein are true. knowing that false statements on this form are punishable by law state that the facts contained herein are true. 1. I have probable cause to believe that on at in Address Clay County Missouri City Name of Offender s committed one or more criminal offense s. 1. I have probable cause to believe that on at in Address Clay County Missouri City Name of Offender s committed one or more criminal offense s. Description of Identity Insert the criminal offenses s that you have probable cause to believe that his offender committed here.

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