This form is to be used by private citizens when requesting criminal charges be filed against another person. Please note that Rule 506 of the Pennsylvania Rules of Criminal Procedure requires that when a private citizen completes this form, it must be submitted to the attorney for the Commonwealth's Office for approval, before it can be filed in a Pennsylvania Magisterial District Court. It may be filed ONLY in a Pennsylvania Magisterial District Court, and NOT in the Philadelphia Municipal Court. No changes may be made to this form, either in content or format, without the express written approval of the Administrative Office of Pennsylvania Courts. Effective date for use of this form is July 1, 1996.