Free Petitioner's Sworn Statement on Eligibility (rev. 11-21-05) - Oregon

Marijuana Possession Diversion Form 3
PETITIONER'S SWORN STATEMENT OF ELIGIBILITY
(Petitioner must file this sworn statement with the marijuana possession diversion petition and agreement.)

(Petitioner must complete this form in print or type.)

Court Name

Court Location

Court Case Number

I have been sworn to tell the truth and swear that I am eligible to participate in a Marijuana Possession Diversion Agreement and that: 1. On the date the offense charged in this case, no other charge of possession of less than one ounce of marijuana was pending against me in Oregon or elsewhere, and I had not been convicted of the offense of possession of less than one ounce of marijuana in Oregon or elsewhere; and I have never participated in a marijuana possession diversion program in Oregon or elsewhere.

2.

Petitioner's Signature

Petitioner's Name (typed or printed)

Today's Date

Subscribed and sworn before day of me this

, 20

.

Notary Public for Oregon / Judge My commission expires .

NC:dc/Marijuana_Diversion_Form_3_11-21-05