Pre-Disposition Home Detention Application Form printable pdf download

PRE-DISPOSITION HOME DETENTION APPLICATION

APPLICATION MUST BE COMPLETED & SUBMITTED BY DEFENDANT’S ATTORNEY

DATE ______________ CASE #_____________________________________ CHARGES______________________________

NAME __________________________________________________ Alias __________________________________________

DATE OF BIRTH__________________SOCIAL SECURITY # ________________________ AGE ___ RACE ___ SEX ___

ADDRESS __________________________________ APT #_____ CITY/STATE ___________________ ZIP ____________

RESIDENCE CANNOT BE SECTION 8 HOUSING OR PUBLIC HOUSING FOR SOME OFFENSES. HOUSING AUTHORITY APPROVAL REQUIRED

* Whose name is the home phone listed under? _____________________________________________________

* Whose name is the residence listed under? _______________________________________________________

(THIS PERSON MUST

MUST GIVE VERBAL PERMISSION TO USE THEIR PHONE FOR HOME DETENTION TO ADULT COURT

MUST

SERVICES BEFORE

BEFORE

BEFORE THE REPORT GOES TO THE JUDGE, AND MUST COME TO ACS AND SIGN A CONSENT FORM BEFORE

BEFORE

STARTING HOME DETENTION.)

HOME PHONE _______________________ WORK PHONE ____________________ CELL __________________________

* Name of home phone service provider: __________________________________ (CenturyLink works best / NO Mediacom)

* NO SPECIAL FEATURES ALLOWED ON PHONE. Do you have special features on telephone service? _________

(SPECIAL FEATURES EXAMPLE: CALLER ID, CALL WAITING, CALL FORWARDING, IN ADDITION NO ANSWERING MACHINE, NO VOICE MAIL, NO MODEM ETC.)

YOU NEED A REGULAR PUSH BUTTON TELEPHONE NOT A CORDLESS.

YOUR PHONE MUST BE IN WORKING ORDER BEFORE YOU START HOME DETENTION

PLACE OF EMPLOYMENT ____________________________________ Work # _______________________

Address __________________________________________CITY / STATE______________________________

Supervisor ___________________________ **** ATTACH CURRENT PAY STUB TO THIS APPLICATION ***

*If self-employed you must provide a copy of your business license with copy of taxes from the prior year *

FEES ASSESSED FOR HOME DETENTION ARE BASED ON VERIFIED HOURLY PAY // First 2-Weeks Fees are due when HD is started

Hours of employment: Monday________

Tuesday_________ Wednesday __________ Thursday ________

Friday _________

Saturday ________

Sunday ____________ Hourly Rate/ Salary: $__________

* ARE YOU CURRENTLY ATTENDING SCHOOL? ___________________________________________________

NAME OF SCHOOL -- ATTACH CURRENT CLASS SCHEDULE

ATTORNEY ________________________ _______ PROBATION/PAROLE OFFICER__________________________

Name and phone

PROSECUTOR ____________________________ Opposed / Not Opposed

# DAYS TO SERVE ________

BEGINNING _______

* NEXT COURT DATE: _____________________

Have you ever been on the Home Detention program before under Court Services? Y / N WHAT YEAR? _______

Successful / Revoked / Absconded ____________

Court Services use only:

Were fees paid in full: Y / N

H:\ACS\Programs\HOME DETENTION\FORMS\Predisposition Application Home Det.doc Revised 7/20/11

Pre-Disposition Home Detention Application Form

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