The information and complaint of C. D. of ................... .............................................................. (yeoman), taken this ............. day of ................., in the year one thousand nine hundred and ......................., before the undersigned, who saith that (etc., stating the offence). Sworn before me, the day and year first above mentioned, at ..............................................................
(Signature)
Justice of the Peace (or as the case may be) for the district of ................