Circuit Court of the State of Oregon for Multnomah County PETITIONER SWORN STATEMENT OF ELIGIBILITY Ͳ DUII Diversion Form 3 (This sworn statement must be filed with DUII diversion forms 1, 2, and 4) (To be filled in by petitioner, please print or type:) Circuit Court Court Name Multnomah County Court Location ________________________ Court Case Number By signing this document, I swear that I am eligible to participate in a driving under the influence of intoxicants (DUII) diversion program in the case described above, and that all of the following are true: 1. I have never been convicted of a felony DUII offense in Oregon or any other place. 2. On the date I sign the attached petition for a DUII diversion agreement: a. There is no charge pending against me in Oregon or any other place, except for the DUII charge in this case, for an offense involving operation of a vehicle while: x under the influence of alcohol, a controlled substance, an inhalant, or any combination of the three; or x having a blood alcohol content above the allowable blood alcohol content; b. I am not participating in a DUII diversion program or any similar alcohol or drug rehabilitation program in Oregon or any other place except a program I may have entered as a result of the charge for the present offense of DUII; and c. There is no charge of an offense pending against me in Oregon or any other place for any degree of aggravated vehicular homicide, murder, manslaughter, criminally negligent homicide, or assault that resulted from the operation of a motor vehicle. 3. During the ten (10) years before the date of the presently alleged DUII offense and during the time between the presently alleged DUII offense and the date I sign the attached petition: a. I have not been convicted in Oregon or any other place for an offense involving the operation of a vehicle while: x under the influence of alcohol, a controlled substance, an inhalant, or any combination of the three; or x having a blood alcohol content above the allowable blood alcohol content; b. I have not participated in a DUII diversion program or any similar alcohol or drug rehabilitation program in Oregon or any other place; and c. I have not been convicted, in Oregon or any other place, on any charge of an offense in any degree for aggravated vehicular homicide, murder, manslaughter, criminally negligent homicide, or assault that resulted from the operation of a motor vehicle. 4. The DUII offense described in the attached petition for which I am charged did not involve any deaths or any physical injury to any other person (“physical injury” means impairment of physical condition or substantial pain—ORS 161.015). 5. At the time of the alleged offense, I did not have a commercial driver’s license. 6. At the time of the alleged offense, I was not operating a commercial motor vehicle. ______ Petitioner's Signature ______ Petitioner’s Name (typed or printed) ____ _____ Today's Date Subscribed and sworn before me this _________ day of ____________________________, 20______. _____________________________________________________ Notary Public for Oregon / Court Clerk / Circuit Court Judge My commission expires _________________________________. 08Ͳ20 (01/08) Distribution: Original – Court (See SLR 4.075) Supplementary Local Rules Fourth Judicial District, Circuit Court of the State of Oregon for Multnomah County Draft Revision to be Effective February 1, 2008 American LegalNet, Inc. www.FormsWorkflow.com