Section 45.208. Form

COMMONWEALTH OF PENNSYLVANIA
PENNSYLVANIA HUMAN RELATIONS COMMISSION
101 SOUTH SECOND STREET, SUITE 300
HARRISBURG, PA 17105

CITATION

RESPONDENT FIRST NAME	MIDDLE NAME	LAST NAME
1.
RESIDENCE ADDRESS	CITY-TWP-BORO-COUNTY	STATE ZIP CODE
2.
BUSINESS ADDRESS
3.
CHARGE
4.
DATES(S) OF PUBLICATION	MANNER OF PUBLICATION	COPY ATTACHED
5.	6.	YES NO
STATUTE OR REGULATIONS	CIVIL PENALTY	TOTAL DUE $
7.	8. $	9.
I VERIFY THAT THE FACTS SET FORTH IN THIS CITATION ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE OR INFORMATION AND BELIEF. THIS VERIFICATION IS MADE SUBJECT TO THE PENALTIES OF SECTION 4804 OF THE CRIMES CODE (18 PA.C.S § 4904) RELATING TOO UNSWORN FALSIFICATION TO AUTHORITIES.
SIGNATURE
10. DATE
REMARKS
11. 12. CITATION NO.

READ THE ATTACHED PLEA AND THE EXPLANATION OF YOUR RIGHTS AND OBLIGATIONS FOR SETTLEMENT OF THIS MATTER. YOU MUST ELECT AN OPTION AND FOLLOW THE APPROPRIATE DIRECTIONS WITHIN FIFTEEN (15) DAYS TO AVOID FURTHER LEGAL ACTION AGAINST YOU.

SHOULD YOU ELECT TO DEMAND A HEARING ON THIS MATTER, FOLLOW THE INSTRUCTIONS ON THE ATTACHED PLEA. YOUR HEARING DATE WILL BE SET BY A HEARING OFFICER. ALL HEARINGS ARE HELD IN HARRISBURG IN THE PENNSYLVANIA HUMAN RELATIONS COMMISSION CONFERENCE ROOM.

NOTICE OF RIGHTS AND OBLIGATIONS

1.	The original of this citation will be filed with the Housing Director of the Pennsylvania Human Relations Commission at Pennsylvania Human Relations Commission, Housing Division, 101 South Second Street—Suite 300, Harrisburg, PA 17105.
2.	Within fifteen (15) days of the issuance or receipt of this citation, you must:
	a. ADMIT TO THE VIOLATION(S) by signing the appropriate plea below and mailing the entire Citation along with an amount equal to the Total Due as specified on the Citation (attached) to the Housing Director, at the address listed above, or;
	b.	DENY THE VIOLATION(S)
		i.	in whole by signing the appropriate plea as specified in Section (b) of the Plea (attached) and mailing the Citation along with an amount equal to the Total Due as specified on the Citation (attached) to the Housing Director at the address listed specified above.
		ii.	in part by signing the appropriate plea as specified in Section ‘‘c’’ of the Plea (attached) below and mailing the Citation along with an amount equal to the Total Due as specified on the Citation (attached) to the Housing Director at the address specified above.
If you deny the violation(s), a formal hearing will be scheduled in Harrisburg at which you may present evidence on your behalf. Failure to appear at the formal hearing will result in the entry of a default judgment against you for the full amount of the civil penalty (‘‘Total Due’’) as specified on the Citation.
3.	All payments must be made by certified or cashier’s check or money order and made payable to the ‘‘Commonwealth of Pennsylvania,’’ and mailed to the Housing Director at the address specified above. Please place the Citation Number on certified or cashier’s check or money order. Personal Checks WILL NOT be accepted.
4.	FAILURE TO RESPOND WITHIN THE TIME SPECIFIED ABOVE will result in the entry of a default judgment against you for the full amount of the civil penalty (‘‘Total Due’’) as specified on the Citation. Failure to pay a civil penalty could result in additional fines and the revocation, suspension or other disciplinary action against any license which you may hold.
	a.	I ADMIT to the violation(s) on the reverse side of this Citation Signature Date
	b.	I DENY the violation(s) on the reverse side of this Citation Signature Date
	c.	I ADMIT to violations Enter Violation Number(s) here have enclosed the amount for these violations and DENY the remaining violation(s) on the reverse side of this Citation Signature Date
PLEASE PLACE THE CITATION NUMBER(S) ON YOUR CERTIFIED OR CASHIER’S CHECK OR MONEY ORDER
Note: A copy of the Pennsylvania Human Relations Commission’s guidelines and policy statement on advertising pursuant to Act 34 is attached and incorporated by reference here unto.