For 1^st time DUI Applicants: The $150.00 fee for the evaluation must be paid to the County Attorney’s Office upon submitting your application for diversion.  If paying by check; please make check payable to: Southeast Kansas Mental Health Center.

 

IN THE DISTRICT COURT OF WOODSON COUNTY, KANSAS

 

STATE OF KANSAS,                          )

                                    Plaintiff,         )

                                                            )

v.                                                         )                                               Case No. ________

                                                            )

_____________________,                        )

                                    Defendant.     )

____________________________)

 

DIVERSION APPLICATION

 

1.         Name:_______________________________________________________

                        ^{First                                          Middle                                     Last}

 

            Any alias used in the last five years:__________________________________________________________
 

2.         Address:______________________________________________________________________________________

                                    Street                                                                    City                          State                         Zip

 

3.         Telephone Numbers:____________________________________________________________________

                                                                Home                                                                       Work

 

4.         Length of residence at given address: ______________________________

 

5.         Previous address:________________________________________________________________________________

                                                                    Street                                    City                          State                         Zip

 

6.         Social Security Number:_________________________________________

 

7.         Race:_________       Sex:__________       Date of Birth:________________

 

8.         Date of Offense:___________________   

 

9.         Charge(s) filed against you:______________________________________________________________________

 

10.       Traffic cases, list arresting officer:_________________________________

 

11.       Driver’s license state and number:_________________________________

            Do you have a CDL?  Yes   f      No   f

 

 

           

12.       Employment (list current and previous employers and dates with each): ___________________________________
 

            ____________________________________________________________________________________________
 

13.       List the name and address of your immediate family:_____________________________________________________

 

           _____________________________________________________________________________________________

 

14.       List your medical history including any mental health treatment or counseling:________________________________
 

           _____________________________________________________________________________________________

 

15.       List any alcohol/drug treatment programs and dates of attendance:

            ________________________________________________________________________________________________________________________

 

16.       List general information of your present financial status.  Please attach pay stubs for the last month.

            a. Employer:__________________________________________________

            b. Length of employment:________________________________________

            c. Previous employer:___________________________________________

            d. Net and Gross Pay:___________________________________________

            e. Paid period:_________________________________________________

            f. Monthly payments owed:______________________________________

            g. Total indebtedness:___________________________________________

 

17.      List any incidence where you were arrested, charged or convicted of crimes whether felony, misdemeanor or traffic.  List the city and state of the incident and result of the incident: _________________________________________________

           
______________________________________________________________________________________________

18.      
Why should you be granted a diversion: _______________________________________________________________

 

            _____________________________________________________________________________________________

 

            _____________________________________________________________________________________________

 

19.     What will prevent you from being charged with a similar offense in the future:_________________________________________________________________________________________

           
______________________________________________________________________________________________

 

 

                                                                                    ___________________________

                                                                                                                        , Defendant