INITIAL APPLICATION FOR PRE-TRIAL DIVERSION IN THE CIRCUIT COURT FOR ________________________ COUNTY STATE OF TENNESSEE VS. __________________________________ ) ) ) ) ) DOCKET NO._________________ DATA CONCERNING DEFENDANT NOTE TO DEFENDANT: ALL QUESTIONS MUST BE ANSWERED COMPLETELY, AND IF NECESSARY, ADDITIONAL PAGES MAY BE ATTACHED. 1. Full Name: ______________________________________________________________ Last First Middle 2. Aliases, nicknames, or changes in name: _______________________________________ 3. Birth Date: _____________________________________ Month Day Year 4. Sex: 5. Height: ________ Weight: _______ Color of eyes: ________ Color of hair: __________ 6. Social Security Number: __________________ Dr. License Number________________ 7. Address________________________________________________________________ M( ) F( ) _________________________________________Telephone______________________ 8. Marital Status: Never Married ( ) Married ( ) Divorced ( ) Spouse Deceased ( ) If married, give spouse's name: ______________________________________________ 1 American LegalNet, Inc. www.FormsWorkFlow.com 9. Parents: Father ______________________________ Living ( ) Deceased ( ) Date of Birth: ____________ Place of Birth: ____________________________ Mother _____________________________ Living ( ) Deceased ( ) Date of Birth: ____________ Place of Birth: ____________________________ 10. Children: Yes ( ) No ( ) If yes, how many ________. (INCLUDE CHILDREN BY ADOPTION) Give names and birth dates of each child: __________________________________ _________________________________ __________________________________ __________________________________ __________________________________ __________________________________ How many of these children live with you?_____________________ 11. Are you obligated by Court to pay child support to any of your children. Yes ( ) No ( ) If yes, are you current: Yes ( ) 12. Education: No ( ) (Account for all schools and military academies) Dates Attended From - To Diploma Received? _______________________________ ______________ __________ ________________________________ ______________ __________ _________________________________ ______________ __________ _________________________________ ______________ __________ Name and location of school 13. Intelligence level, (if known): _______________ 14. Has a psychiatric or psychological evaluation ever been performed? Yes ( ) No ( ) 2 American LegalNet, Inc. www.FormsWorkFlow.com 15. If "yes", what diagnosis, if any, was made? ____________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 16. Prior work record of defendant: Type of Job a. Name/Address of Employment Supervisor Dates Held Reason for Termination ________________________________________________________________________ b. ________________________________________________________________________ c. ________________________________________________________________________ d. ________________________________________________________________________ e. ________________________________________________________________________ 1. Did any of employments require a security clearance? Yes ( ) No ( ) 2. Have you ever been refused an employment bond? Yes ( ) No ( ) 3. If the answer to any of the above is "yes", explain: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 17. List any noteworthy physical characteristics or disabilities of the Defendant. ________________________________________________________________________ 18. List all residences since age 18. Dates From - To _____________________ Streets and Numbers City State ________________________________________________ 3 American LegalNet, Inc. www.FormsWorkFlow.com _____________________ _____________________ ________________________________________________ _____________________ ________________________________________________ _____________________ ________________________________________________ _____________________ ________________________________________________ _____________________ ________________________________________________ _____________________ ________________________________________________ _____________________ ________________________________________________ _____________________ ________________________________________________ _____________________ ________________________________________________ _____________________ 19. ________________________________________________ ________________________________________________ Past and/or present membership in organizations, and community awards: Name and Address __of Organization__ Social, Fraternal, Professional or Other Office Held Date From - To ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 20. Have you ever been detained, held, arrested, indicted or summoned into court as a defendant, or placed on probation, or have you ever been ordered to deposit bail or collateral for the violation of any law? Include all court martials while in military service. Yes ( ) No ( ) 4 American LegalNet, Inc. www.FormsWorkFlow.com If "yes", list date, nature of offense or violation, name and location of the court or place of hearing, and the penalty imposed or other disposition of each case. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ OFFENSE-RELATED DATA 21. Were there any co-defendants in the case? Yes ( ) No ( ) 22. What conviction and sentence, if any, were imposed on co-defendants? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 23. Have you been charged in this case with other separate (not lesser included) offenses? Yes ( ) No ( ) If yes, list offenses: _____________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 24. If other separate offenses were charged, list disposition(s): ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 5 American LegalNet, Inc. www.FormsWorkFlow.com 25. Is the victim related by blood or marriage to defendant? Yes ( ) No ( ) If the answer is "yes", what is the relationship? _________________________________ _______________________________________________________________________ 26. Is the victim an employer or employee of defendant? No Employer Employee 27. ( ) ( ) ( ) Is the victim acquainted with the defendant? No Casual acquaintance Friend Intimate ( ( ( ( ) ) ) ) 28. Was there evidence the defendant was under the influence of narcotics or dangerous drugs that actually contributed to the offense? Yes ( ) No ( ) 29. Was there evidence the defendant was under the influence of alcohol that actually contributed to the offense? Yes ( ) No ( ) 30. Has the defendant ever received counseling for alcohol or drug abuse? Yes ( ) No ( ) 31. Is the defendant a resident in the community? Yes ( ) No ( ) If "no", where does the defendant reside? ______________________________________ 32. Defendant's recitation of the facts of the offense: ________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 33. If restitution was ordered to be paid in this case, how much restitution could the defendant pay monthly: $____________per month. 6 American LegalNet, Inc. www.FormsWorkFlow.com 34. List five (5) references who have known defendant more than ten (10 ) years who are not relatives: Name Address Phone Years Known ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 35. Have you ever been adjudicated delinquent in Juvenile Court? Yes ( ) No ( ) If "yes", list: _____________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 36. List all prior lawful spouses or significant others: Name Present Address Date Married or Known ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 37. Has any member of your immediate family ever been convicted of a felony? Yes ( ) No ( ) If yes, if you attend to live with this individual, give name, relationship, and present address of such individual: ________________________________________________________________________ ________________________________________________________________________ 7 American LegalNet, Inc. www.FormsWorkFlow.com CHRONOLOGY OF THE CASE A. Date of offense ___________________________________________________________ B. Date of arrest ____________________________________________________________ C. Date of preliminary hearing _________________________________________________ D. Date of arraignment _______________________________________________________ E. Date of trial _____________________________________________________________ Realizing that the above answers are material to this case and under penalty of perjury, I do hereby swear to each of the above answers and that I have completed the report to the best of my ability. I understand that I have a continuing duty to disclose if any of the information changes while my application for diversion is pending. ____________________ Date __________________________________________ Defendant __________________________________________ County Sworn to and subscribed before me this _______day of _____________20_____. _________________________________ NOTARY PUBLIC My Commission Expires: ____________ 8 American LegalNet, Inc. www.FormsWorkFlow.com