For 1st time DUI
Applicants: The $150.00 fee for the evaluation must be paid to the
IN THE DISTRICT COURT OF
STATE OF KANSAS, )
Plaintiff, )
)
v. ) Case
No. ________
)
_____________________, )
Defendant. )
____________________________)
1. Name:_______________________________________________________
First Middle Last
Any
alias used in the last five years:__________________________________________________________
2. Address:_____________________________________________________
3. Telephone
Numbers:____________________________________________
4. Length
of residence at given address: ______________________________
5. Previous
address:______________________________________________
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