Ninth Judicial Circuit Pretrial Intervention Intake Information printable pdf download

NINTH JUDICIAL CIRCUIT PRETRIAL INTERVENTION INTAKE INFORMATION

THE PTI PROGRAM IS A PRIVILEGE, NOT EVERYONE IS OFFERED THIS PRIVILEGE. PLEASE TAKE ADVANTAGE

OF THIS OPPORTUNITY TO RESOLVE THE CRIMINALCHARGES PENDING AGAINST YOU AT THIS TIME. PTI IS

VOLUNTARY AND YOUR PARTICIPATION IN THIS PROGRAM IS YOUR DECISION. FAILURE TO DISCLOSE PERTINANT

INFORMATION MAY RESULT IN YOUR CASE BEING RETURNED FOR PROSECUTION. DO NOT SKIP ANY QUESTIONS. IF

THE QUESTION DOES NOT APPLY, PUT NONE OR N/A IN THE SPACE PROVIDED.

Rev.4/2016

LAST NAME_____________________________FIRST _________________MIDDLE ___________________JR/III_____

SOCIAL SECURITY NUMBER ________--_____--_________

CELL # (_____) ______--_______

ADDRESS: ____________________________________________________________________________________________

STREET/P.O. BOX

INCLUDE APT. #

CITY

STATE

ZIP CODE

MAIDEN NAME/NICKNAMES: ______________________ RACE/SEX ___________

BIRTHDATE _____________

STATE WHERE YOU WERE BORN __________ DRIVER’S LICENSE # _____________________ STATE _________

PLEASE LIST WHERE YOU HAVE LIVED FOR THE LAST 2 YEARS_______________________________________

** Are you a US Citizen? Yes / No

Are you Military, Active or Reserves? ____________________

**Are you a US Veteran? Yes/ No

If YES Approx. Date of Discharge: _______________________

Do you have an attorney for the PTI Charge(s)? Attorney Name: _____________________________

PLEASE CHECK EACH SPACE THAT APPLIES TO YOU:

__ MARRIED ___ WIDOWED ___ DIVORCED ___ SEPARATED ___ NEVER MARRIED ___COHABITATING

__ EMPLOYED FULLTIME __ PARTIME __ UNEMPLOYED __ DISABLED __ RETIRED

HOUSEHOLD INCOME ___ 0-5,000 __5-10,000 __10-20,000 __20-30,000 __30-40,000 __40-50,000 __ OVER 50,000

________ FULL TIME STUDENT _______ PART TIME STUDENT ________ NOT A STUDENT

NAME OF COLLEGE, TECHNICAL OR HIGH SCHOOL NOW ATTENDING ____________________________________

TOTAL NUMBER OF YEARS OF SCHOOL COMPLETED _____________ (Ex: HIGH SCHOOL=12)

ARE YOU CURRENTLY EMPLOYED? _______________________________________JOB TITLE ___________________

LOCATION: ____________________________________ FOR HOW LONG? _____________________________________

LIST YOUR PLACES OF EMPLOYMENT FOR THE LAST TWO YEARS _______________________________________

______________________________________________________________________________________________________

*HAVE YOU EVER APPLIED, BEEN REJECTED, OR PARTICIPATED IN ANY PTI BEFORE? _______

If yes, list which one _______________

*HAVE YOU EVER APPLIED OR BEEN IN ANY (AEP) ALCOHOL EDUCATION PROGRAM

BEFORE? ______

ARE THERE ANY OTHER CRIMINAL CHARGES PENDING AGAINST YOU AT THIS TIME IN ANY OTHER

COURT?

IF SO

DESCRIBE.___________________________________________________________________________________________

Ninth Judicial Circuit Pretrial Intervention Intake Information