For 1st 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