COURT OF COMMON PLEAS FAIRFIELD COUNTY, OHIO GENERAL DIVISION COMMUNITY CONTROL APPLICATION PRE-SENTENCE INVESTIGATION INTERVIEW QUESTIONNAIRE ATTENTION :______________________________________ (NAME) In order to prepare its pre-sentence investigation, the Fairfield County Community Control Department is requesting information about you, your case, and your background. Please fill out this questionnaire as completely and honestly as possible. The information you provide will be verified to determine if it is truthful and accurate. A Pre-Sentence Investigator will review this form with you, and may ask additional questions or request additional information at a later time, prior to sentencing. An interview has been scheduled for you on ______________, at _____________. (Date) (Time) This interview will be with _______________________________________. (Disregard above if a date and time are not indicated hereon) Honorable Richard E. Berens Honorable David A. Trimmer Fairfield County Common Pleas Court: 224 E. Main Street Room #101 - Lancaster, Ohio 43130 Revised 01/13/17 -1American LegalNet, Inc. www.FormsWorkFlow.com PLEASE PRINT WITH BLUE OR BLACK INK. Name: ______________________________________ Address: ______________________________________________ ______________________________________________________ Phone Number: ____________________________ Race: White Asian Black/African American (Check One) American Indian Bi-Racial Hawaiian/Pacific Islander (For record keeping purposes only) DOB: _______________________________ Age: _______________________________ SSN: _______________________________ Sex: Male Female Height: ________________ Weight: _________________ Eyes: ________________ Hair: __________________ Scars/Marks/Tattoos/Piercings: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Highest Grade Completed: _______________________________________ School Attended: _______________________________________________ Are You a US Citizen: Yes No If No, Country of Citizenship: _____________________________ Place of Birth (City, State): _______________________________________ Criminal History List any previous charges/convictions: Date Charge Court Disposition _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Have you ever been on probation/community control? Yes No If yes, please give the details of the offense. Date Charge Violations Successful Completion Y/N _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ -2American LegalNet, Inc. www.FormsWorkFlow.com Are there any pending (outstanding) criminal charges against you at this time for which you have not been sentenced? If so, list: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Social History Marital Status: Married Divorced Separated Widowed Single Significant Others Name: ________________________________________ Age: ___________________ Occupation: __________________________ Address: ______________________________________________________ _____________________________________________________________ Phone: _____________________________________ Criminal History: Yes No If Yes, list charges/convictions: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Father's Name: ________________________________________ Age: ___________________ Occupation: __________________________ Address: ______________________________________________________ _____________________________________________________________ Phone: _____________________________________ Criminal History: Yes No If Yes, list charges/convictions: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Mother's Name: ________________________________________ Age: ___________________ Occupation: __________________________ Address: ______________________________________________________ _____________________________________________________________ Phone: _____________________________________ Criminal History: Yes No If Yes, list charges/convictions: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ -3American LegalNet, Inc. www.FormsWorkFlow.com Siblings Name: ________________________________________ Age: ___________________ Occupation: __________________________ Address: ______________________________________________________ _____________________________________________________________ Phone: _____________________________________ Criminal History: Yes No If Yes, list charges/convictions: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Siblings Name: ________________________________________ Age: ___________________ Occupation: __________________________ Address: ______________________________________________________ _____________________________________________________________ Phone: _____________________________________ Criminal History: Yes No If Yes, list charges/convictions: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Siblings Name: ________________________________________ Age: ___________________ Occupation: __________________________ Address: ______________________________________________________ __________________________________