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1. Personal Information This section is complete This section is incomplete
2. Family Information This section is complete This section is incomplete
3. Financial Information This section is complete This section is incomplete
4. Education & Employer Information This section is complete This section is incomplete
5. Benefits / Health Information This section is complete This section is incomplete
6. Legal Information This section is complete This section is incomplete
7. Signature This section is complete This section is incomplete

Personal Information

Name
Nickname / Alias(s)
Address
City
State
Zip Code
Phone Number
Email Address
Contact Phone Number
Name of Contact
How long have you been at above noted address?
How many times have you moved in the last year?
Last five years?
Age
Date of Birth
Sex
Race
Height
Weight
Eye Color
Hair Color
Place of Birth - City
Place of Birth - State
Are you a U.S. Citizen?
1. Yes
1. No
If not, where?
List all other states in which you have resided:
Marital Status
Spouse's (Former Spouse's) Name
Continue

Family Information

List Names, Addresses and Phone Numbers of the Following Family Members:
Father
Mother
Brothers
Sisters
Children
Spouse's Parents
How many minor children do you have?
With whom do they reside?
Are you ordered to pay child support?
How much per month?
Continue |Go Back

Financial Information

Are you behind on any bills or payments (Include Rent, Child Support, Utilities, etc.)?
List What/How Much Behind on Each Debt
Continue |Go Back

Education & Employer Information

Last Grade Completed in School
Where?
G.E.D. / Diploma
When?
Where?
Present Employer
Employer Address
City
State
Zip Code
Phone Number
Type of Work
Wage
Percentage of Time Employed in Last 12 Months
Have you ever been fired?
1. Yes
1. No
If yes, why?
Continue |Go Back

Benefits / Health Information

What forms of financial support do you receive?
1. SSI
2. SSD
1. Welfare
2. Vision Card
1. WIC
2. Retirement
1. Spousal Support
2. Medical Card
Do you have any medical issues?
What?
Do you have health insurance?
Name of Provider
Name of Primary Physician
List Any Mental Health Diagnosis
Are you currently receiving mental health treatment/counseling?
List All Medications You Are Prescribed and Taking
Are you prescribed any medications you are not currently taking?
What / Why
List All Illicit/Recreational Drugs You Have Ever Used (include alcohol)
Date Last Used Alcohol
Date Last Used Alcohol
Marijuana
Marijuana
Meth
Meth
Coke
Coke
List out any other illicit/recreational drugs used
Were substances involved in your current offense?
How?
Have you ever had a substance abuse problem or addiction?
Explain:
How have substances effected your life?
Have you ever attended in-patient D/A treatment?
Outpatient?
Where?
When?
Did you complete?
Last AA/NA Attendance
Continue |Go Back

Legal Information

List Make, Model, Description and Tag Numbers of Any Vehicles You Drive:
List All Prior Law Violations
Date
Date
Charge(s)
Where:
Date
Date
Charge(s)
Where:
Date
Date
Charge(s)
Where:
Have you been on court-ordered supervision in the past?
Are you currently on supervision anywhere else?
Where?
Name of Officer
Have you ever served time as a result of a sentence or a revocation?
When?
Where?
Do you have any pending cases?
What?
Where?
Have You Ever Submitted DNA to the KBI Databank?
When?
Are you a registered offender?
If your registration current?
Continue |Go Back

Signature

Date
Date
Signature

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Judicial Council

Judicial Branch

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Butler County Judicial Center 201 W Pine, Suite 101

El Dorado, Kansas 67042

Phone: 316-322-4358
1-800-595-3651

Fax: 316-321-9486

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