IN THE CIRCUIT COURT, SIXTH JUDICIAL CIRCUIT
IN AND FOR PASCO AND PINELLAS COUNTIES, FLORIDA
ADMINISTRATIVE ORDER NO. 2019-006 PI-CIR
RE: ORDER AUTHORIZING USE OF COMPLAINT/ARREST AFFIDAVIT AND
COUNTYWIDE MANDATED NOTICE TO APPEAR FORM
In order to update the Administrative Order for Pinellas County Local Ordinance
Violations, it has become necessary to update the Administrative Order mandating
complaint/arrest affidavit and notice to appear forms.
In accordance with Article V, section 2, Florida Constitution, Rule of Judicial
Administration 2.215, and § 43.26, Florida Statutes, it is
ORDERED:
1. Notice to Appear: The Notice to Appear/Ordinance Violation Form, which is
Attachment A to this Administrative Order, has been approved by the Court as the official
complaint instrument for the prosecution of county and municipal ordinance violations within the
jurisdiction of Pinellas County. It has also been approved as the official complaint instrument for
the prosecution of misdemeanor cases within the jurisdiction of Pinellas County where a notice to
appear is appropriate.
a. Effective immediately, all agencies in Pinellas County who are authorized to issue Notice
to Appear forms for County Court are hereby authorized to use the form contained in
Attachment A and must exclusively use the Notice to Appear/Ordinance Violation Form
in Attachment A.
b. These paragraphs do not apply to the Fish and Wildlife Conservation Commission who
shall continue to issue citations on the required state forms issued by the agency.
2. Complaint/Arrest Forms: The Adult and Juvenile Complaint/Arrest Affidavit forms,
which are contained as Attachment B to this Administrative Order, have been approved by the
Court as the official complaint/arrest instruments within the jurisdiction of Pinellas County where
an arrest is involved.
a. Effective immediately, all agencies authorized to issue complaint/arrest affidavits in
County or Circuit Court must exclusively use the Adult and Juvenile Complaint/Arrest
Affidavit forms contained in Attachment B.
b. A separate affidavit must be used for each charge for adult and juvenile arrests. Multiple
charges may not be input on the same affidavit.
3. The Court may update the attachments to this Administrative Order without an amendment
to this Administrative Order.
2
Administrative Order 2014-067 PI-CIR is hereby rescinded.
DONE AND ORDERED in Chambers at St. Petersburg, Pinellas County, Florida this
_____ day of January 2019.
ORIGINAL SIGNED ON JANUARY 23, 2019
BY ANTHONY RONDOLINO, CHIEF JUDGE
Attachment A: Notice to Appear/Ordinance Violation Form
Attachment B: Adult Complaint/Arrest Affidavit Form
Juvenile Complaint/Arrest Affidavit Form
cc: All Pinellas Judges
The Honorable Bernie McCabe, State Attorney
The Honorable Bob Dillinger, Public Defender
The Honorable Ken Burke, Clerk of the Circuit Court, Pinellas County
The Honorable Bob Gualtieri, Sheriff, Pinellas County
Gay Inskeep, Trial Courts Administrator
Ita M. Neymotin, Regional Counsel, Second District
Ngozi Acholonu, Assistant Regional Counsel
Jewel White, County Attorney, Pinellas County
Mark Woodward, County Administrator, Pinellas County
Harold Vielhauer, Florida Fish and Wildlife Conservation Commission, General Counsel
Major Joseph Franza, Florida Highway Patrol, Troop Commander
Captain Maurice Hensley, Florida Highway Patrol, Pinellas Park District Commander
Tonya Rainwater, Justice CCMS Project Sponsor
Martin Rose, BTS Executive Director
Tim Staney, CJIS Coordinator
Local Law Enforcement Agencies
Local Code Enforcement Officers
Bar Associations, Pasco and Pinellas Counties
Law Libraries, Pasco and Pinellas Counties
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Fill in the below listed information completely
Related Defendants
Defendant Name
Race Sex DOB
Defendant Name
Race Sex DOB
Related Law Enforcement Officers
Name
Law Enforcement Agency
Name
Law Enforcement Agency
Related Civilian Witnesses
Witness Name
Race Sex DOB
Address
City, State, Zip
Home Telephone Work Telephone
Witness Name
Race Sex DOB
Address
City, State, Zip
Home Telephone Work Telephone
Related Evidence
Evidence
Evidence
Evidence
I hereby certify the above list of witnesses and tangible
evidence is true and correct to the best of my knowledge.
Signature of Officer
Date
Take right thumb print of defendant
if not identified with proper photo
identification.
Right Thumb Print
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VICTIM NOTIFICATION INFORMATION
Defendant’s Name:
Court Case#
Victim’s Name:
Race:________ Sex: ________ DOB:_________
Social Security #
Person ID:
Address:
City:
State:________________ Zip: ________________
Home Telephone:
Work Telephone:
Other Contact Telephone:
Is the victim a witness?
Was Victim Rights Brochure given?
Is the victim in the hospital?
Victim’s Name:
Race: Sex: DOB:
Social Security #
Person ID:
Address:
City:
State: Zip:
Home Telephone:
Work Telephone:
Other Contact Telephone:
Is the victim a witness?
Was Victim Rights Brochure given?
Is the victim in the hospital?
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Obtain proper identifications from defendant and both defendant
and officer must sign the citation. If the defendant has no photo
identification, obtain right thumbprint of defendant on rear side
of the complaint copy of the citation.
Provide the defendant his or her copy of the citation. Complete
the schedule of witnesses and evidence on the reverse side of
the complaint copy. Misdemeanor cases also require the
victim information be completed on the reverse side of the
State Attorney copy. Return complaint and State Attorney
copy to the Clerk of the Court. A worksheet detailing
investigative costs must be included on all criminal violations.
Attach a copy of the offense report for misdemeanor offenses.
OFFICER’S NOTES:
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IF THE FACE OF THIS NOTICE INDICATES THAT YOU HAVE THE
OPTION OF PAYING A FINE OR APPEARING IN COURT, AND YOU
CHOOSE TO PAY THE FINE, YOU MAY WITHIN 7+,57<
&$/(1'$5 DAYS OF THE DATE OF THE OFFENSE(S) PRESENT THIS
NOTICE IN PERSON OR SEND A CHECK OR MONEY ORDER MADE
PAYABLE TO THE CLERK OF THE CIRCUIT COURT TO:
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VISA, MASTERCARD, AMERICAN EXPRESS OR ELECTRONIC CHECK
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LOCATION.
IF YOU DO NOT PAY THE FINE WITHIN 7+,57< &$/(1'$5
DAYS, OR ENTER A WRITTEN PLEA OF NOT GUILTY IN PERSON OR
BY MAIL, YOU MUST APPEAR IN COURT ON THE DATE INDICATED
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I HEREBY ENTER MY PLEA OF GUILTY OR NOLO CONTENDERE
AND WAIVE MY RIGHT TO APPEAL OR OBTAIN JUDICIAL REVIEW.
I UNDERSTAND THE NATURE OF THE CHARGE AGAINST ME. I
UNDERSTAND MY RIGHT TO HAVE COUNSEL AND WAIVE THIS
RIGHT AND THE RIGHT TO A CONTINUANCE. I WAIVE MY RIGHT
TO TRIAL BEFORE A JUDGE.
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COMPLAINT/ARREST AFFIDAVIT – CIRCUIT/COUNTY COURT – PINELLAS COUNTY, FLORIDA
OBTS # REPORT # DOCKET #
Person ID SSN#
C
harge Description
Felony Misdemeanor Warrant Traffic Ordinance Traffic Citation # (if any) Court Case #
Charge
Defendant’s Name (Last, First, Middle) DOB Sex Race Ht Wt Hair Eyes Skin
Alias DL # State Scars/Marks/Tattoos/Physical Features
Local Address (Street, City, State, Zip Code) Telephone Place of Birth Citizenship
Permanent Address (Street, City, State, Zip Code) Telephone Employed by / School
Weapon Seized Type
Yes No
Indication of Y N UNK
Drug Influence
Indication of Mental Y N UNK
Health Issues
Indication of Y N UNK
Alcohol Influence
Co-Defendant’s Name (Last, First, Middle) DOB Sex Race
In Custody
Yes No
Felony Misdemeanor
Co-Defendant’s Name (Last, First, Middle) DOB Sex Race
In Custody
Yes No
Felony Misdemeanor
The undersigned swears that he/she has reasonable grounds to believe that the above named defendant on the day of , ,
at approximately
a.m. p.m., at ,in Pinellas County did:
Contrary to Florida Statute/Ordinance .
ARREST DATE: Time a.m. p.m. Aggravating/Mitigating Factors
.
Booking Officer: Amount of Bond Bond Out Date Time a.m. p.m.
Victim Notified of Advisory?
Yes No Injuries to Victim? Yes No Medical Treatment to Victim? Yes No
The Court reviewed this complaint and finds there:
is probable cause is not probable cause to detain defendant Bond Action, if any:
.
The probable cause determination is passed for:
24 Hrs 24 Hrs on showing of extraordinary circumstances
Pursuant to F.S. 92.525 and under penalty of perjury, I declare that I have
read the foregoing document and that the facts in it are true.
Declarant Signature Agency
Printed Name Declarant ID#
REQUEST FOR INVESTIGATIVE COSTS, F.S. 938.27(1)
DATE OFFICER HOURS X PAY RATE OR COST
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
OTHER – Describe __________________________ ___________________________ .
_____________
COCR59 (Revised 1/
19)
Copies to:
WhiteCourt GreenJail
Goldenrod - Defendant
Blue - State Attorney Pink - 2IILFHU&RS\
Continuation sheet ______Yes ______ No TOTAL $
Defendant Court Case No:
ADVISORY AND SOLVENCY HEARING
The above named Defendant came before me for Advisory and Solvency hearing and was advised by me of the charge(s)
against him; his right to remain silent; that any statements by him may be used against him; his right to counsel, and, if he is
financially unable to afford counsel, that counsel forthwith will be appointed; of his right to communicate with his counsel,
family or friends, and that reasonable implementation will be afforded him to contact the foregoing.
I FURTHER CERTIFY THAT:
ޭ A. Defendant has advised the Court that he has retained counsel or will retain counsel.
ޭ B. The Court investigated Defendant’s solvency and found the Defendant financially able to secure counsel.
ޭ C. The Court investigated Defendant’s solvency and provisionally appointed the Public Defender.
ޭ D. The Defendant waived the right to counsel at the first appearance only.
DATE AND TIME JUDGE
ޭ I hereby waive the right to counsel at the first appearance only.
ޭ I, having been found solvent and financially able to secure counsel, hereby waive counsel until my attorney files
an appearance in this case or until I file a written request for a review of my solvency and ability to secure counsel.
DEFENDANT’S SIGNATURE
Thumb Print
I HEREBY acknowledge receipt of a copy of the foregoing Complaint and Advisory.
DEFENDANT’S SIGNATURE DEFENDANT’S ATTORNEY’S SIGNATURE DATE
COCR59 (Revised 01/19)
COCR59_Juvenile (Revised 10/2014)
OBTS # Law Enforcement Report # Docket #
Date Arrested'DWH5HIHUUHGScreen for Diversion
Child: Admits Denies Misdemeanor Felony Ordinance Court Case #
Charge
Child’s Name (Last, First, Middle) Person ID SSN#
Alias DOB Sex Race HT WT Hair Eyes Skin
DL # / State ID (if any) State School Attends Grade
Local Address (Street, City, State, Zip Code) Home or Contact Telephone
Father Name Address (Street, City, Zip Code)
Mother Name Address (Street, City, Zip Code)
Physical Custodian /Other - Name Address (Street, City, Zip Code)
Co-Defendant (Last, First, Middle) Co-Defendant is:
Child
Adult
The undersigned swears that he/she has reasonable grounds to believe that the above named defendant on the day of , ,
at approximately
a.m. p.m., at ,in Pinellas County did:
Contrary to Florida Statute/Ordinance .
)
JUVENILE COMPLAINT/ARREST AFFIDAVIT – CIRCUIT COURT –
UNIFIED FAMILY COURT,
IN AND FOR PINELLAS COUNTY, FLORIDA
Pursuant to F.S. 92.525 and under penalty of perjury, I declare that I have
read the foregoing document and that the facts in it are true.
Declarant Agency
Printed Name Declarant ID#
Request for Investigative Costs, F.S. 938.27(1)
Date Officer Hours X Pay Rate or Cost
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Other – Describe _________________________________________________________.
Total $____________________
Copies to:
White - Court
Blue - State Attorney
Green - Jail / Dept. of Juvenile Justice
Pink - Officer Copy
If drug charge, Presumptive Test Positive
Continuation sheet ______Yes ______ No
VICTIM NOTIFICATION INFORMATION
Defendant’s Name
Court Case #
1.Victim’s Name Race Sex DOB
Social Security # Party ID Person ID
Address
City State Zip
Home Telephone-Work Telephone Email
Other Contact Telephone
(Cell Phone, Relative, Neighbor)
Other Address for Victim
Is the victim a witness ޭ Was Victim Rights brochure given? ޭ Is the victim in a hospital? ޭ
Name of Hospital?
2.Victim’s Name Race Sex DOB
Social Security # Party ID Person ID
Address
City State Zip
Home Telephone-Work Telephone Email
Other Contact Telephone
(Cell Phone, Relative, Neighbor)
Other Address for Victim
Is the victim a witness ޭ Was Victim Rights brochure given? ޭ Is the victim in a hospital? ޭ
Name of Hospital?
3.Victim’s Name Race Sex DOB
Social Security # Party ID Person ID
Address
City State Zip
Home Telephone-Work Telephone Email
Other Contact Telephone
(Cell Phone, Relative, Neighbor)
Other Address for Victim
Is the victim a witness ޭ Was Victim Rights brochure given? ޭ Is the victim in a hospital? ޭ
Name of Hospital?
4.Victim’s Name Race Sex DOB
Social Security # Party ID Person ID
Address
City State Zip
Home Telephone-Work Telephone Email
Other Contact Telephone
(Cell Phone, Relative, Neighbor)
Other Address for Victim
Is the victim a witness ޭ Was Victim Rights brochure given? ޭ Is the victim in a hospital? ޭ
Name of Hospital?
C2C559 (Revised 01/19)
