Crim. Form 47 (Rev 7/31/18) JUSTICE OF THE PEACE COURT OF THE STATE OF DELAWARE IN AND FOR COUNTY COURT NO. DATE: DEFENDANT: CASE #: Driving Under the Influence of Alcohol/Drug - First Offenders Program Disposition Worksheet COURT COST $ 35 .00 VIDEO PHONE FEE $ 1 .00 DELJIS FEE $ 1 .00 COURT SECURITY FEE $ 10 .00 POLICE FUND $ 15 .00 COST OF PROSE CUTION $250 .00 AMBULANCE FEE $ 10 .00 ( Applied after arrest date of 12/23/14) OTHER TOTAL (Circle one): $322.00 or $ PAYMENT SCHEDULE: Defendant shall pay $ today/weekly/biweekly/monthly Beginning // until paid in full. PROBATION: Defendant is placed on Court Probation commencing // for a period of Months. COMPLIANCE REVIEW DATE (select one): Enter Date: // OR (Circle one): 10th 25th of (month), 20 . CONDITIONS OF PROBATION (check all that apply): 1. Defendant need not return to court. 2. Defendant must, within 72 hours arrange for a DUI evaluation and pay the cost at time of Evaluation. 3. Delaware residents are advised to contact Division of Motor Vehicles to comply with IID installation requirement. 4. Defendant must pay for and complete the approved DUI course by //. 5. Defendant must pay all court costs and assessments. 6. Presentence investigation for restitution? Yes No. 7. DOJ waives BAC to below 0.15 Yes No. American LegalNet, Inc. www.FormsWorkFlow.com