MINNESOTA COURT RULES

CRIMINAL PROCEDURE

Forms provided here are for reference purposes. To download forms to fill out please visit the Minnesota Courts website.

FORM 4A. GROSS MISDEMEANOR CHARGING BY TAB CHARGE

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STATE OF MINNESOTA	DISTRICT COURT
COUNTY OF ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________	____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ JUDICIAL DISTRICT
State of Minnesota,
Plaintiff,	TAB CHARGE PURSUANT TO
vs.	MINN. R. CRIM. P. 4.02, SUBD. 5(3)
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________,
Defendant.

To:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________County District Court and		____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________	County Jail
From: Arresting Officer: (Please Print) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________			Badge Number: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Pursuant to Minnesota Rules of Criminal Procedure 4.02, subd. 5(3), the above-named officer hereby requests that the named defendant be processed for the designated Gross Misdemeanor (GM) indicated below and as defined by Minnesota Rules of Criminal Procedure 1.04 (b).
Defendant Name: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________			DOB: ____/____/____
Driver's License No. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________		State: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________	Date of Offense: __/__/__
City of Occurrence: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________		Controlling Agency: MN - ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Control Number/ICR: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________		Court File No. (Provided by Court/Jail): ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

(Check Boxes)	Designated GM Offense	Charge	Penalty (must check one)		MOC
			2nd Degree (E)	3rd Degree (F)	Circle E or F
□	UI Alcohol	169A.20, 1(1)	□ 169A.25	□ 169A.26	J_____501 E F
□	UI Controlled Substance	169A.20, 1(2)	□ 169A.25	□ 169A.26	J_____601 E F
□	UI Hazardous Substance	169A.20, 1(3)	□ 169A.25	□ 169A.26	J_____H01 E F
□	UI Combination	169A.20, 1(4)	□ 169A.25	□ 169A.26	J_____G01 E F
□	Alcohol .08 or More Within 2 Hours of Driving	169A.20, 1(5)	□ 169A.25	□ 169A.26	J_____W01 E F
□	Alcohol .04 or More Within 2 Hours of Driving - Commercial Vehicle	169A.20, 1(6)	□ 169A.25	□ 169A.26	J_____K01 E F
□	Schedule I or II Controlled Substance	169A.20, 1(7)	□ 169A.25	□ 169A.26	J_____S01 E F
□	Refusal to Submit To Test	169A.20, 2	□ 169A.25	□ 169A.26	J_____R01 E F
□	Other (specify): ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Court Status: (Check one)
□	Defendant incarcerated in ______________ County Jail to be held in custody pending court appearance.
□	Defendant released on his/her own recognizance and assigned the following court date.
	Date: ____/____/____		Time: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
	Location: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________			County Courthouse
	Address: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Bail/Bond Status: (Check One)				Date: ___/___/___
□	Maximum $12,000 bail under Minnesota Statutes, section 629.471, or conditional release under Minnesota Statutes, section 169A.44.
□	Bail was posted in the amount of $________.
□	Bond was posted in the amount of $________.
□	No bail/bond was required.
Dated:	____/____/____		____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
			Officer's signature
			____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
			Officer's Name and Badge Number
			(if different from arresting officer)

(Added effective September 29, 2000; amended effective for criminal actions commenced or arrests made after 12 o'clock midnight March 1, 2006.)