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Office of the Revisor of Statutes

CRIMINAL PROCEDURE

FORM 4A. GROSS MISDEMEANOR CHARGING BY TAB CHARGE

_
STATE OF MINNESOTADISTRICT 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		ChargePenalty (must check one)MOC
2nd Degree (E)3rd Degree (F)Circle E or F
□UI Alcohol169A.20, 1(1)□ 169A.25□ 169A.26J_____501 E F
□UI Controlled Substance169A.20, 1(2)□ 169A.25□ 169A.26J_____601 E F
□UI Hazardous Substance169A.20, 1(3)□ 169A.25□ 169A.26J_____H01 E F
□UI Combination169A.20, 1(4)□ 169A.25□ 169A.26J_____G01 E F
□Alcohol .08 or More Within 2 Hours of Driving169A.20, 1(5)□ 169A.25□ 169A.26J_____W01 E F
□Alcohol .04 or More Within 2 Hours of Driving - Commercial Vehicle169A.20, 1(6)□ 169A.25□ 169A.26J_____K01 E F
□Schedule I or II Controlled Substance169A.20, 1(7)□ 169A.25□ 169A.26J_____S01 E F
□Refusal to Submit To Test169A.20, 2□ 169A.25□ 169A.26J_____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.)