POWER OF ATTORNEY

PCN ______________

State of South Dakota

In Circuit Court

Magistrate Division

County of_______________

____________Judicial Court

State of South Dakota (Plaintiff)

Vs

___________________________________

(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