11. Where a member of a Court shall direct the issue of any summons in a criminal case without payment of a fee, he shall deliver to the person applying for the issue of such summons a certificate or statement in writing signed by such member, and stating-
(a) the names of the complainant and accused,
(b) the nature of the offence complained of,
(c) that the summons is to be issued without payment of fee, and
(d) the date when it was signed.