Name of Defendant *

First Name

Last Name

Address of Defendant *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number of Defendant

(###)

###

####

Defendant Date of Birth *

MM

DD

YYYY

Ethnicity of Defendant *

American Indian or Alsaka Native

Asian

Black or African American

Native Hawaiian or Other

White

Marital Status of Defendant *

Married

Single

Separated

Divorced

Widowed

Defendant Highest Educational Level *

Less than high school degree

High school graduate or equivalent

Some college credit, but no degree

Trade/technical/vocational training

Associate degree

Bachelor's degree

Graduate degree

Yearly Household Income *

Less than $10,000

$10,000 - $15,000

$15,000-$20,000

$20,000 or more

Defendant Prior Criminal History *

Yes

No

Has defendant ever failed to appear in the past *

Yes

No

Has the defendant been offered OR or SOR *

Yes

No

Does the defendant need housing *

Yes

No

Does the defendant need job training or placement? *

Yes

No

Does the defendant need counseling for substance abuse or other matters? *

Yes

No

Does the defendant need legal services for noncriminal matters? *

Yes

No

Name of Judge *

First Name

Last Name

Next Court Date *

MM

DD

YYYY

Name of Person Submitting This Application (if not Defendant) *

First Name

Last Name