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. Return to Woodson County Attorney, 105 W. Rutledge, Yates Center. KS 66783

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:_________________________________

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: ____________________________

________________________________________________________________________________________________________________________

___________________________

, Defendant