Traffic Diversion Application

Application for Traffic Diversion
Defendant's Attorney
Next Court Date
Full Name
Age
Address
Phone
Phone Number with Area CodeFormat: (000) 000-0000.
City
State
Zip
Date of Birth
Month
Day
Year
City and State Where Born
Sex
Marital Status
Email
example@example.com
Present Job
Employer
Address
Job Title
Work Phone
Phone Number with Area CodeFormat: (000) 000-0000.
Salary
Per
How Long
Previous Work Experience
Employer
Address
Job Title
Work Phone
Phone Number with Area CodeFormat: (000) 000-0000.
Salary
Per
How Long
Do you currently have a valid Driver's License?
If no, state the reason for suspension and what jurisdiction.
If suspended, can you get a valid Driver’s License within the 4 months of signing the diversion agreement?
Please list all states where you have obtained a valid driver’s license in the last 10 years.
State
State
State
(Please be aware if you were a holder of a Commercial Driver’s License at the time of offense, you are ineligiblefor the diversion program)
Previous Criminal/Traffic Offense Record
State ALL offenses for which you have been arrested or charged at any time and in any jurisdiction. Include: expunged, dismissed, diverted, juvenile, traffic and alcohol related offenses.
Criminal Offense
Criminal Offense
When
Where
Outcome
Criminal Offense
Criminal Offense
When
Where
Outcome
Criminal Offense
Criminal Offense
When
Where
Outcome
Traffic Offense
Traffic Offense
When
Where
Outcome
Traffic Offense
Traffic Offense
When
Where
Outcome
Traffic Offense
Traffic Offense
When
Where
Outcome
Traffic Offense
Traffic Offense
When
Where
Outcome
Do you have any outstanding warrants? If yes, where?
Are you currently on bond supervision diversion or probation? If yes, where?
Certification
State in your own words and in detail the facts of the current case which caused charges to be filed:
I declare, verify, certify, or state under the penalty of perjury under the laws of the State of Kansas, that I have personally read or have had read to me the above application for Diversion and responses thereto and that all information contained in the forgoing application for Diversion, including but not limited to my listing of previous criminal record in section 6, is true and correct. I understand that if any of this information is not true and correct, this will be a basis for denial or revocation of Diversion. I agree that if an undisclosed criminal offense or DUI is discovered after Diversion has been granted, a criminal justice report, KBI report, Police Department or Sheriff's Office report, and/or Department of Revenue report may be admitted as evidence in any court, without foundation, to prove prior traffic or criminal offenses for the purpose of revocation of Diversion in this matter.
Release of Information
I hereby authorize the District Attorney's Office to release any information in the District Attorney's file pertaining to this offense for which I am charged to Johnson County Mental Health Center, DCF, and the investigating Law Enforcement Agencies, or any other such person or agencies for use in determining whether I am a suitable candidate for diversion. I further authorize any person, agency, or organization to release and provide, upon request, any information to the office of the District Attorney in consideration of any application for Diversion.

I further authorize any person, agency, or organization that is conducting an evaluation or treatment as part of the diversion application or the diversion agreement to release information to any other person, agency, or organization as needed for the evaluation or treatment process.

Revised 2/2020
Defendant
Date
Should be Empty:

Application for Traffic Diversion

Date of Birth

Present Job

Previous Work Experience

Previous Criminal/Traffic Offense Record

Criminal Offense

Criminal Offense

Criminal Offense

Traffic Offense

Traffic Offense

Traffic Offense

Traffic Offense

Release of Information