02:03:01:03Power of attorney form.

The following form, or any other form that substantially complies with it, shall be used for offenses included on the schedule of offenses adopted pursuant to SDCL 16-2-21 and where a power of attorney option is provided: POWER OF ATTORNEY PCN ______________ State of South Dakota In Circuit Court Magistrate Division County of_______________ ____________Judicial Court State of South Dakota (Plaintiff) Vs ___________________________________ (Defendant) No. _____________HP THE UNDERSIGNED PEACE OFFICER COMPLAINS AND STATES THAT ON OR ABOUT AT OR NEAR (LOCATION/MILE POST) AT TIME A.M. P.M. _________________ ____________________________________ ________ WITHIN THE COUNTY AND STATE AFORESAID NAME HEIGHT SEX _____________________________ ________ _____ ADDRESS WEIGHT _____________________________ ________ CITY STATE BIRTH DATE _____________________________ ________ ____________ DRIVER'S LICENSE NO. STATE _____________________________ ________ DID UNLAWFULLY OPERATE _________ PARK ______ VEHICLE MAKE _______________ BODY STYLE _____________ STATE LICENSE NO. YEAR STATE FR______Y _____________________________ ______ _______ ______N AND THEN AND THERE COMMIT THE FOLLOWING OFFENSE TO WIT: PETTY OFF _____ MIS ______ DESCRIBE VIOLATION: _________________________________________________ CDL ____Y____N C Veh.____Y____N____E _________________________________________________ Haz. Materials ____Y____N in violation of SDCL_________________________________ _____Municipal SPEEDING _____Interstate _____Other ______M.P.H. IN ______M.P.H. ZONE OFFICER ISSUING SUMMONS NO. CITY COUNTY STATE ___________________________ _____ ______________ _________ _______ POWER OF ATTORNEY ____________________________________ I hereby deposit with the Clerk of Courts of __________________________ County, South Dakota, as a cash appearance bond, the sum of $ ________________________ and understand that my initial appearance will be located in the city of ____________________________________. a m. on _____________________________________ at ________________________________ p.m. If I desire to contest this matter, I will appear at the date, time, and place for my initial appearance or contact the clerk of courts before that date and ask the clerk to reschedule the date for my initial appearance. If I do not appear or contact the clerk of courts within the time period, (or if after the court date is set, I fail to appear,) I hereby plead guilty to the charge, and direct the clerk to apply the money deposited as bond herewith to the payment of the fine and costs assessed against me. __________________ Cash taken by Officer - Officer signed I have read this document and have been given a copy. Signed ____________________________________________________________________________ Defendant Date THE SIGNED COPY MUST BE ENCLOSED WITH MONEY IN THE ENVELOPE PROVIDED

Source: 27 SDR 53, effective December 4, 2000.