ࡱ> OQN 7bjbjT~T~ 8V66/_____sss8ls/++AAA$' "___AA_A_A:,fA-nFs  0/R]#]#f]#_f4/]# %: INITIAL APPLICATION FOR PRE-TRIAL DIVERSION IN THE CIRCUIT COURT FOR ________________________ COUNTY STATE OF TENNESSEE ) ) VS. ) DOCKET NO._________________ ) __________________________________ ) DATA CONCERNING DEFENDANT NOTE TO DEFENDANT: ALL QUESTIONS MUST BE ANSWERED COMPLETELY, AND IF NECESSARY, ADDITIONAL PAGES MAY BE ATTACHED. 1. Full Name: ______________________________________________________________ Last First Middle 2. Aliases, nicknames, or changes in name: _______________________________________ 3. Birth Date: _____________________________________ Month Day Year 4. Sex: M ( ) F ( ) 5. Height: ________ Weight: _______ Color of eyes: ________ Color of hair: __________ 6. Social Security Number: __________________ Dr. License Number________________ 7. Address________________________________________________________________ _________________________________________Telephone______________________ 8. Marital Status: Never Married ( ) Married ( ) Divorced ( ) Spouse Deceased ( ) If married, give spouse's name: ______________________________________________ 9. Parents: Father ______________________________ Living ( ) Deceased ( ) Date of Birth: ____________ Place of Birth: ____________________________ Mother _____________________________ Living ( ) Deceased ( ) Date of Birth: ____________ Place of Birth: ____________________________ 10. Children: Yes ( ) No ( ) (INCLUDE CHILDREN BY ADOPTION) If yes, how many ________. Give names and birth dates of each child: __________________________________ _________________________________ __________________________________ __________________________________ __________________________________ __________________________________ How many of these children live with you?_____________________ 11. Are you obligated by Court to pay child support to any of your children. Yes ( ) No ( ) If yes, are you current: Yes ( ) No ( ) 12. Education: (Account for all schools and military academies) Dates Attended Diploma Name and location of school From - To Received? _______________________________ ______________ __________ ________________________________ ______________ __________ _________________________________ ______________ __________ _________________________________ ______________ __________ 13. Intelligence level, (if known): _______________ 14. Has a psychiatric or psychological evaluation ever been performed? Yes ( ) No ( ) 15. If "yes", what diagnosis, if any, was made? ____________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 16. Prior work record of defendant: Name/Address Reason for Type of Job of Employment Supervisor Dates Held Termination a. ________________________________________________________________________ b. ________________________________________________________________________ c. ________________________________________________________________________ d. ________________________________________________________________________ e. ________________________________________________________________________ 1. Did any of employments require a security clearance? Yes ( ) No ( ) 2. Have you ever been refused an employment bond? Yes ( ) No ( ) 3. If the answer to any of the above is "yes", explain: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 17. List any noteworthy physical characteristics or disabilities of the Defendant. ________________________________________________________________________ 18. List all residences since age 18. Dates From - To Streets and Numbers City State _____________________ ________________________________________________ _____________________ ________________________________________________ _____________________ ________________________________________________ _____________________ ________________________________________________ _____________________ ________________________________________________ _____________________ ________________________________________________ _____________________ ________________________________________________ _____________________ ________________________________________________ _____________________ ________________________________________________ _____________________ ________________________________________________ _____________________ ________________________________________________ _____________________ ________________________________________________ 19. Past and/or present membership in organizations, and community awards: Name and Address Social, Fraternal, Date __of Organization__ Professional or Other Office Held From - To ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 20. Have you ever been detained, held, arrested, indicted or summoned into court as a defendant, or placed on probation, or have you ever been ordered to deposit bail or collateral for the violation of any law? Include all court martials while in military service. Yes ( ) No ( ) If "yes", list date, nature of offense or violation, name and location of the court or place of hearing, and the penalty imposed or other disposition of each case. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ OFFENSE-RELATED DATA 21. Were there any co-defendants in the case? Yes ( ) No ( ) 22. What conviction and sentence, if any, were imposed on co-defendants? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 23. Have you been charged in this case with other separate (not lesser included) offenses? Yes ( ) No ( ) If yes, list offenses: _____________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 24. If other separate offenses were charged, list disposition(s): ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 25. Is the victim related by blood or marriage to defendant? Yes ( ) No ( ) If the answer is "yes", what is the relationship? _________________________________ _______________________________________________________________________ 26. Is the victim an employer or employee of defendant? No ( ) Employer ( ) Employee ( ) 27. Is the victim acquainted with the defendant? No ( ) Casual acquaintance ( ) Friend ( ) Intimate ( ) 28. Was there evidence the defendant was under the influence of narcotics or dangerous drugs that actually contributed to the offense? Yes ( ) No ( ) 29. Was there evidence the defendant was under the influence of alcohol that actually contributed to the offense? Yes ( ) No ( ) 30. Has the defendant ever received counseling for alcohol or drug abuse? Yes ( ) No ( ) 31. Is the defendant a resident in the community? Yes ( ) No ( ) If "no", where does the defendant reside? ______________________________________ 32. Defendant's recitation of the facts of the offense: ________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 33. If restitution was ordered to be paid in this case, how much restitution could the defendant pay monthly: $____________per month. 34. List five (5) references who have known defendant more than ten (10 ) years who are not relatives: Name Address Phone Years Known ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 35. Have you ever been adjudicated delinquent in Juvenile Court? Yes ( ) No ( ) If "yes", list: _____________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 36. List all prior lawful spouses or significant others: Name Present Address Date Married or Known ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 37. Has any member of your immediate family ever been convicted of a felony? Yes ( ) No ( ) If yes, if you attend to live with this individual, give name, relationship, and present address of such individual: ________________________________________________________________________ ________________________________________________________________________ CHRONOLOGY OF THE CASE A. Date of offense ___________________________________________________________ B. Date of arrest ____________________________________________________________ C. Date of preliminary hearing _________________________________________________ D. Date of arraignment _______________________________________________________ E. Date of trial _____________________________________________________________ Realizing that the above answers are material to this case and under penalty of perjury, I do hereby swear to each of the above answers and that I have completed the report to the best of my ability. I understand that I have a continuing duty to disclose if any of the information changes while my application for diversion is pending. ____________________ __________________________________________ Date Defendant __________________________________________ County Sworn to and subscribed before me this _______day of _____________20_____. _________________________________ NOTARY PUBLIC My Commission Expires: ____________      PAGE 1 fh o p r  )2TV(-@BFHM\kw] ^ x""&& - -v-z-------000001p3377777777777jhug0JUhpujhpuUhS hug5\hughug5>*\ hug>*Q,-fghp q r / 0 f z { $a$ B C _ `  Z [ HI`-/v12def34}~dfg !VW9:^_DE;<,-ffg89NO)*rs^MN()qrY  UV677\ ] !L!M!!!!!-"."x"y""""""##$#n#o###$$`$$a$^ 0^`0`$a$$$%%J%K%%%%%"&#&m&n&&&''h'i'''''' ((((L(M(X(r((((T)U)))F*G******C+D+++++%,&,p,q, 0^`0q,, - -i-t-u-----9.:.....//x/z///00_0`0` 0^`0h^h`0000011`1a11111G2H2c2d222$3%3n3o3p33333$`a$^`33(4)4z4{444555555 5!5r6s6t6666777777:7`:7;7_7`7a7b77777777777777777777777777hpuhughaa0JmHnHujhug0JU hug0J6&P1h:p;/ =!"#$% ^ 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH DA`D Default Paragraph FontViV 0 Table Normal :V 44 la (k ( 0No List 4@4 Header  !4 @4 Footer  !.)@.  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