Record Of Criminal Cases/traffic Violations Attachment "C" Form
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1Record of Criminal Cases/Traffic Violations
Name_____________________________________________
________________________
Social Security Number
Please indicate whether the matter described below involves a criminal matter, or a minor traffic violation not involving
drugs/or alcohol.
Criminal Matter
Moving Traffic Violation
Parking Violation
Date of Incident (or time period involved):_____________________________________ Age at time of incident _______________
Location: __
______
___
________________________________________________________________________________________
City
County
State
Title of complaint or indictment: _________________________________________________________________________________
Court file number _____________________________________ Date(s) the complaint or indictment was filed: _________________
Name and complete address of court or entity with possession of documents:
Name of Court: _______________________________________________________________________________________
Address: _____________________________________________________________________________________________
City: _____________________________ State: _______ Zip: _________ Telephone Number: _______________________
Name and complete address of law enforcement agency involved:
Name: ______________________________________________________________________________________________
Address: _____________________________________________________________________________________________
City: _____________________________ State: _______ Zip: _________ Telephone Number: _______________________
Name and complete address of entity bringing charges:
Name: ______________________________________________________________________________________________
Address: _____________________________________________________________________________________________
City: _____________________________ State: _______ Zip: _________ Telephone Number: _______________________
Name and complete address of attorney retained in defense of this matter:
Name of Attorney: _____________________________________________________________________________________
Address: _____________________________________________________________________________________________
City: _____________________________ State: _______ Zip: _________ Telephone Number: _______________________
Date first heard: ________________________________
Charge(s) at time of arrest/citation: _______________________________________________________________________________
Charge(s) at time of trial: _______________________________________________________________________________________
Final Disposition: _____________________________________________________________________________________________
____________________________________________________________________________________________________________
Brief description of incident as well as circumstances leading up to and surrounding the same: (continue on separate page if
necessary): __________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
***Attach, where applicable, certified copies of docket sheet(s), the charging documents, police records, etc., as well as the
judgment of convictions, the presentence investigation (if applicable) and any other relevant pleadings.
Attachment “C”
(Make additional copies as needed)
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