Form 421 - Form For Notice Of Violation
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1Form No. 421
County Diversion
Programs
ADDISON
282 Boardman Street
PO Box 881
NOTICE OF VIOLATION
Middlebury, VT 05753
802-388-3888
BENNINGTON
You are being charged with a violation of law as indicated below.
439 Main Street
Bennington, VT 05201
802-447-1595
______Minors Misrepresenting Age, Procuring, Possessing or Consuming Alcoholic
CALEDONIA
Beverages (7 V.S.A. Section 656)
24 Bagley Street
St. Johnsbury, VT 05819
Complaint #_______________________________
802-748-8732
AND OR
CHITTENDEN
184 King Street
Burlington, VT 05401
______Marijuana Possession by a Person under 21 Years of Age, one ounce or less (18
802-864-1585
V.S.A. Section 4230b)
ESSEX
91 Courthouse Drive
Complaint #_______________________________
Guildhall, VT 05905
802-676-3502
FRANKLIN
1. As required by law, you must provide this officer with your correct name and
120 N. Main St.
address.
St. Albans, VT 05478
802-524-7006
2. Within 15 DAYS, you must contact the County Diversion’s Youth Substance Abuse
GRAND ISLE
Safety Program (YSASP) at the address or phone number circled to your left.
120 N. Main St.
St. Albans, VT 05478
3. Do not send any money to pay any legal penalty at this time. There is a program fee
802-524-7006
required by the YSASP.
LAMOILLE
4. Until you have finished all conditions of the program, you must inform the YSASP office
221 Main Street
PO Box 148
of any changes in your name or address.
Hyde Park, VT 05655
802-888-5871
ORANGE
If you contact the Youth Substance Abuse Program within 15 days and complete all
PO Box 58
conditions of the program, this violation will be voided and no penalty will be imposed.
Chelsea, VT 05038
802-685-3172
ORLEANS
If you fail to contact the Youth Substance Abuse Program within 15 days or fail to
273 Main Street, Suite 1
Newport, VT 05855
complete all conditions of the program, the ticket for this violation will be issued. At that
802-334-8224
time, you may contest the charge with the Judicial Bureau.
RUTLAND
50 Center Street
Rutland, VT 05701
If the Judicial Bureau finds you in violation, you will have to pay a fine and your privilege
802-786-3840
to operate a motor vehicle in Vermont will be suspended. The cost of your car insurance
WASHINGTON
322 North Main Street,
may increase substantially. If you hold a license from another state, that state will revoke
Suite 5
Barre, Vermont 05641
your privilege to operate a vehicle also.
Phone: 802 479-1900
WINDHAM
You may have other tickets or citations. For example, if you were driving, you may have been
32 Walnut Street
Brattleboro, VT 05302
given a ticket or criminal citation for operating a vehicle under the influence. Address your
802-257-0361
response to those tickets or citations to the Judicial Bureau or State’s Attorney as explained on
WINDSOR
those documents.
211 North Main Street
PO Box 474
White River Jct, VT 05001
802-295-5078
__________________________________________________________________
Law Enforcement Officer
Phone #
Department Name
Date of violation _____________________
11/15 SML
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