APPLICATION WILL NOT BE ACCEPTED WITHOUT PAYMENT OF A $25.00 NON-REFUNDABLE APPLICATION FEE AT THE TIME OF FILING.

Charges filed:*

Date of offense:*

Court date:*

Case or Ticket number:*

Defense Attorney:*

Telephone:*

Address:*

City, ST:*

Please answer all questions to the best of your ability. You can enter "NA" for any field that doesn't apply to you.

Full Name:*

Telephone:*

Address:*

City:*

State:*

Zip Code:*

Age:*

Date of Birth:*

Sex:*

Race:*

State your license is in:*

Is it a CDL:*

No Yes

Home Phone:*

Work Phone:*

Marital Status:*

Single Married

If married, Spouses name:

Children's names and ages:

Nearest Contact (person who would know your whereabouts):

Name:

Address:*

Telephone:*

Relation to you:*

Present employer:*

Phone:*

Address:*

City, ST:*

How long:*

Title:*

Hourly Wage:*

Monthly Salary:*

If unemployed, what is your source and amount of income?

Spouse:

Parents:

Welfare:

Unemployment:

Other (explain):

Education (name of school):

Middle School:

High School:*

Graduate:*

Yes No

College:*

Years completed:*

Degree:

Vo-Tech:

Military Service:

Branch of Service:

Date of discharge:

Type of discharge:

PSYCHOLOGICAL COUNSELING/TREATMENT: (List any you have received in the last 5 years. Describe the kind of counseling/treatment and the location and date of service):*

DRUG TREATMENT/COUNSELING: (Have you ever participated in drug/alcohol treatment or counseling? If yes, when, where and reason.):*

PREVIOUS CRIMINAL ARRESTS/CONVICTIONS OR DIVERSIONS: (Have you ever been detained, arrested or charged with any offense of the law? List ALL arrests (even if no charges filed.) Include the offense and year and state of any Convictions, Diversions or Deferred Prosecutions including Juvenile Offenses.):*

TRAFFIC OFFENSE CONVICTIONS or TRAFFIC DIVERSIONS: (Within last 5 years, include the offense and the year and state): *

Do you have any traffic citations of criminal charges pending in Kansas of any other city, county, or state:*

Yes

No

If yes, where:

Vehicle Insurance Information:

Company:*

Policy Number:*

Agent's Name:*

Telephone:*

Explain why you believe you would successfully complete the Diversion Program:*

I hereby apply for status as a participant in the Diversion Program. I request that the Butler County Attorney temporarily delay trial proceedings against me in order to permit the County Attorney’s consideration of this application. I agree that any time taken to consider this application and the rescheduling for trial, should I be denied, will be assessed against me in determining my right to a Speedy Trial. I understand that the final decision to commence trial proceedings or to defer prosecution in my case rests entirely with the Butler County Attorney.

I authorize the Diversion Coordinator to conduct an investigation to determine suitability for this program. I understand that any information furnished or authorized by me, to be given to the Diversion Coordinator in connection with this investigation, will be kept confidential.

I understand that a false answer to any question in this application, or withholding information requested, may be grounds for recommendation against placement into this program or removal after placement in the program, in which case, the Butler County Attorney will resume prosecution of the original charges. I also understand that the Butler County Attorney may file additional criminal charges against me if I give any false information in this application.

I agree to the above and provide the following as an electronic signature:*

Agree

Name and date:*

There is a $25 non-refundable application fee to process this application. This fee does not guarantee acceptance to the program.

There is a 3.60% + $0.09 fee for using this online service.

If you want to pay citations to Clerk of District Court please visit www.citepayusa.com/ks OR if you want to pay for Juvenile Justice fees visit their webpage.