1. On or about the _____________ day of ____________________, 19______, defendant, maliciously, and without probable cause therefor, caused the plaintiff to be arrested under a warrant issued by _________________, a justice court judge, on a charge of (as the case may be).

2. Before the commencement of this action, this charge was judicially investigated, the prosecution ended, and the plaintiff discharged.

Wherefore plaintiff demands judgment against defendant in the sum of _______________ dollars and costs.