FORM 81A-C
rule 81A.12(1)

IN THE SUPREME COURT
OF THE NORTHERN TERRITORY
OF AUSTRALIA
AT [DARWIN OR ALICE SPRINGS]

File No: [file number]

BETWEEN

[Name of Complainant]
    Complainant

and

[Name of Defendant]
         Defendant

COMPLAINT

The Complaint of [name of complainant], a police officer, is taken on [date], before the undersigned, a Justice of the Peace, who, on oath, states that:

(1)	The defendant, [name] of [address], was granted bail for the offence of [offence] on [date bail was granted] by [name of person who granted bail].

(2)	The defendant undertook to appear before this honourable Court under that bail on [date of appearance].

(3)	On [date of conduct resulting in breach of bail], the defendant engaged in conduct that [would result in a breach of [his/her] bail undertaking / resulted in a breach of a condition of the grant of bail] contrary to section 37B(1) of the Bail Act 1982.

Particulars of breach
[set out particulars of breach]

Taken before me at [place] on [date].

…………………………..
Justice of the Peace