Free INITIAL APPLICATION FOR PRE-TRIAL DIVERSION - Tennessee

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 Aliases, nicknames, or changes in name: _______________________________________ Birth Date: _____________________________________ Month Day Year Sex: M( ) F( )

2. 3.

4. 5. 6. 7.

Height: ________ Weight: _______ Color of eyes: ________ Color of hair: __________ Social Security Number: __________________ Dr. License Number________________ 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) Give names and birth dates of each child: _________________________________

If yes, how many ________.

__________________________________

__________________________________ __________________________________ __________________________________ __________________________________ How many of these children live with you?_____________________

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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 From To ______________ ______________ ______________ ______________ Diploma Received? __________ __________ __________ __________

Name and location of school _______________________________ ________________________________ _________________________________ _________________________________

13. 14. 15.

Intelligence level, (if known): _______________ Has a psychiatric or psychological evaluation ever been performed? Yes ( ) No ( )

If "yes", what diagnosis, if any, was made? ____________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

16.

Prior work record of defendant: Name/Address of Employment Reason for Termination

Type of Job a. b. c. d. e.

Supervisor

Dates Held

________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 1. 2. 3. Did any of employments require a security clearance? Have you ever been refused an employment bond? If the answer to any of the above is "yes", explain: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Yes ( ) Yes ( ) No ( ) No ( )

17.

List any noteworthy physical characteristics or disabilities of the Defendant. ________________________________________________________________________

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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 __of Organization__ Social, Fraternal, Professional or Other Date From - To

Office Held

________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 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. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

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OFFENSE-RELATED DATA

21. 22.

Were there any co-defendants in the case?

Yes ( )

No ( )

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 ( ) Was there evidence the defendant was under the influence of alcohol that actually contributed to the offense? Yes ( ) No ( ) Has the defendant ever received counseling for alcohol or drug abuse? Yes ( ) Is the defendant a resident in the community? Yes ( ) No ( ) No ( )

29.

30. 31.

If "no", where does the defendant reside? ______________________________________

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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. List five (5) references who have known defendant more than ten (10 ) years who are not relatives: Name Address Phone Years Known

34.

________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 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: ________________________________________________________________________ ________________________________________________________________________

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CHRONOLOGY OF THE CASE

A. B. C. D. E.

Date of offense ___________________________________________________________ Date of arrest ____________________________________________________________ Date of preliminary hearing _________________________________________________ Date of arraignment _______________________________________________________ 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: ____________

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