Duii Diversion Form 1 - Uniform Duii Diversion Petition And Agreement
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1DUII Diversion Form 1
UNIFORM DUII DIVERSION PETITION AND AGREEMENT
DUII diversion forms 2, 3, and 4 must be filed with this form and served on the district attorney or city attorney who filed the charge.
Petitioner is to provide the information required in this box as follows (print or type):
Petitioner’s Name and Residence:
Court where charge was filed
For Court File Stamp
and petition is to be submitted:
________________________________________________________
First
Middle
Last
________________________
________________________________________________________
Court Name
Street
City
State
ZIP
________________________
________________________________________________________
Court Case Number
Mailing Address (if different)
Date of Birth:
Phone #:
Driver License:
________________________
Date of DUII Offense
____ /____ /_____
_______________
_____________ _____
Month Day Year
Number
State
Petitioner’s Agreement and Waiver
I, the petitioner, request that this court grant a diversion under ORS 813.200 to 813.270 in this case for the charge of driving under
the influence of intoxicants (DUII). If the court allows this petition:
1) I agree to all of the items listed under the “Agreement with the Court” section of DUII Diversion Form 2 (located on the back of
this form unless filed electronically) and have read and understand all of the other information in Form 2 and Form 2A;
2) I plead guilty or no contest to the DUII charge as shown in the plea petition (DUII Diversion Form 4) submitted with this
diversion petition;
3) I waive (give up) the rights listed in the plea petition; and
4) I waive my former jeopardy rights under the federal or state constitutions and ORS 131.505 to 131.525 in any future action on
the charge or any other offenses based on the same criminal incident.
__________________________________
__________________________________
__________________
Petitioner’s Signature
Petitioner’s Name (typed or printed)
Date
COURT ORDER
For Court File Stamp
☐ (allows) ☐ (denies)
The court
the petition for diversion. The DUII charge is alleged to
have occurred on _________________, 20____. If “allowed,” this court withholds entry of a
judgment of conviction pending completion or termination of the diversion, and orders that:
1) The diversion period is one year beginning on ____ /____ /_____ and ending
on ____ /____ /_____;
2) The petitioner must pay fees to the court for the diversion as required by statute unless waived or deferred; Fees: $__________
☐Due immediately, or ☐Payment schedule: $____ per month due by the ____ day of each month beginning ____ /____ /____
3) The petitioner ☐ (must) ☐ (need not) attend a victim impact panel approved by this court and ☐ (must) ☐ (need not) pay a
participation fee to that program;
Victim Impact Panel Date: __________________________________
4) The petitioner must pay court-appointed attorney fees in an amount of $_______ on a schedule set by the clerk of the court;
5) The petitioner ☐ (must) ☐ (need not) file a motion at the end of the diversion requesting that the DUII charge be dismissed;
6) The petitioner ☐ (must) ☐ (need not)install and use an ignition interlock device in any vehicle operated by the petitioner
during the period of the agreement (beginning on ____ /____ /_____ and ending on ____ /____ /_____) when the petitioner
has driving privileges. If the petitioner need not install an ignition interlock device, the petitioner meets the requirements for a
medical exemption in accordance with the rules adopted by the Oregon Department of Transportation;
7) Other: ___________________________________________________________________________________________________
__________________________________
__________________________________
__________________
Name of Judge
Signature of Judge
Date
Form Revised on January 1, 2014
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