Page 1 of 1 Vermont Superior Court www.vermontjudiciary.org Docket Number: NOTICE OF INTENT TO REFER TO PROGRAM Defendant Information TO: (Name) (Mailing Address) (Date of Birth) (Email Address) (Offense) (Docket No.) (Incident No.) (Offense) (Docket No.) (Incident No.) I intend to refer you to the Diversion ProgramTamarack Programto resolve the offense(s) described above. If you accept this referral, you must sign this form and either: 1.meet with a Program representative at the courthouse TODAY; or2.contact the Program WITHIN SEVEN (7) DAYS OF THE DATE OF THIS NOTICE. You may contact the Program by telephone, mail or in person. The contact information for the Program in this County is: Successful resolution of your case through the Program is subject to: (1) your agreement to participate in the Program under the terms set forth below and (2) your successful completion of the Program. If you decide not to accept this referral, your case will proceed forward in court. Dated Signature of State222s Attorney or Deputy ACCEPTANCE OF PROGRAM REFERRAL I hereby accept the offer of the State's Attorney to participate in the Program indicated above. I understand that if I choose not to participate in the Program or I am found to be ineligible for the Program, I must appear in Court whenever my case is scheduled for a hearing. My mailing address is: The address set forth above is a correct mailing address for me.The address set forth above is not a correct mailing address.My NEW correct mailing address is: Home Phone: Cell Phone: Business Phone: Email Address: I agree to immediately inform the Court if my address changes. I understand that if my case is scheduled for a Court hearing and I fail to attend the hearing, the Court may issue an arrest warrant and require bail. Dated Signature of Defendant Dated Signature of Parent/Guardian (if Defendant is a minor) cc: State, Defendant, Diversion 200-00081 226 Notice of Intent to Refer to Program (1/2018) American LegalNet, Inc. www.FormsWorkFlow.com