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4. Case Number
5. Date
   Date
9. Do you speak and read English fluently?

   1. Yes
   2. No
10. Do you need an interpreter?

    1. Yes
    2. No
11. If yes, what language?
13. If you do not speak and read English fluently it is your responsibility to have this Diversion Application interpreted for you. Please provide the name, phone number and email of your interpreter for our records and any future correspondence.
17. First Name*
18. Last Name*
20. Maiden Name or any other names used within the last five (5) years.
22. Email Address*
23. Phone (Cell)
24. Phone (Work)
26. Address1
28. Address2
30. City
31. State
32. Zip
36. Previous Address

    List all addresses at which you lived in the past five (5) years. 

38. List all States that you have lived in other than Kansas.
42. The following information will not be used to determine diversion eligibility. Information is required to update personal identifiers in case file.
46. Date of Birth
    Date of Birth
47. Birth Place
48. Social Security Number
50. Race
51. Sex
52. Height
54. Weight
55. Eye Color
56. Hair Color
60. Employer (Current)
61. How Long?
63. Address
64. Phone Number
68. Previous Employer
69. How Long?
71. Address
72. Phone Number
76. Arrest/Ticket Date
    Arrest/Ticket Date
77. Charges

    Include all charges & cases that you are applying for diversion.

81. Do you have a valid drivers license?

    1. Yes
    2. No
82. Can you obtain a valid drivers license?

    1. Yes
    2. No
83. Do you carry a Commercial Drivers License?

    1. Yes
    2. No

    You are not eligible for a diversion on a traffic offense if you carry a CDL.

85. Drivers License Number (include State)
86. Do you have valid auto insurance? (List insurance company & policy #)
90. Parents Name
92. First Name
93. Last Name
95. Address1
97. City
98. State
99. Zip
103. First Name
104. Last Name
106. Address1
108. City
109. State
110. Zip
116. Are you:

     1. Single
     2. Married
     3. Divorced
     4. Separated
     5. Widowed
117. Spouses Name, Address and Phone Number
121. Do you have minor children?

     1. Yes
     2. No
122. How many?

     1. 1
     2. 2
     3. 3
     4. 4+
123. Are you supporting these children?

     1. Yes
     2. No
125. Is there a support order for any or all of these children?

     1. Yes
     2. No
126. If yes, list name and location of Court and Case Number/County.
130. Name, Address and Phone Number of someone who will always know your whereabouts.
134. Are you currently experiencing any mental or physical problems?

     1. Yes
     2. No
135. If yes, state the nature of problem and name of treating physician, therapist.
139. Have you participated in any alcohol/drug treatment program?

     1. Yes
     2. No
140. If yes, state program and dates of attendance.
144. List any prior incidents where you were arrested, charged or convicted of crimes whether felony, misdemeanor or traffic. List the City/County/State and Date where the incident occurred and the results of the incident.
148. Have you ever been on probation or parole?

     1. Yes
     2. No
149. If yes, list location, dates and what type of charge.
153. Have you ever participated in a Diversion in this State or any other State?

     1. Yes
     2. No
154. If yes, list the city, county, state, dates, charges and if you completed it successfully.
158. Do you use liquor?

     1. Yes

     1. No
159. Do you use narcotics?

     1. Yes

     1. No
163. Finney County Attorney's Office is committed to giving back to the community. A portion of every Diversion Agreement is donated to a local non-profit. Applicants may specify where they would like their contribution to go. Please choose one (1) or two (2) local charities that you would like to contribute to.
165. Non-Profit Contribution (Choice #1)*
     -- Select One --ABC Pregnancy Care CenterBig Brothers/Big Sisters of Finney CountyBoy Scouts of AmericaBuffalo Living Legacy FundCASA- Spirit of the PlainsChurch of the Nazarene, Garden CityCity on a Hill, Inc.Garden City Community Day CareCrimestoppers- Garden City & Finney CountyCounty 4-H ClubsFinney County Health Coalition- LivewellFinney County Humane SocietyFinney County Senior CenterFinney County United WayFriends of Lee Richardson ZooGarden City Parks & RecreationGCCC Endowment AssociationGirl Scouts of Kansas HeartlandHHS Booster Club ScholarshipsKansas Children's Service LeagueKansas Food Bank- Food4Kids- Finney CountyLeave a Legacy FoundationMagic Hopes Therapeutic Horsemanship ProgramMeals on WheelsMiles of SmilesRussell Child DevelopmentSalvation Army- Local ChapterSANE/SART of Finney CountySeeds of Hope- Jail MinistrySouthwest Boxing ClubWestern Kansas Child Advocacy Center
166. Non-Profit Contribution (Choice #2)
     -- Select One --ABC Pregnancy Care CenterBig Brothers/Big Sisters of Finney CountyBoy Scouts of AmericaBuffalo Living Legacy FundCASA- Spirit of the PlainsChurch of the Nazarene, Garden CityCity on a Hill, Inc.Garden City Community Day CareCrimestoppers- Garden City & Finney CountyCounty 4-H ClubsFinney County Health Coalition- LivewellFinney County Humane SocietyFinney County Senior CenterFinney County United WayFriends of Lee Richardson ZooGarden City Parks & RecreationGCCC Endowment AssociationGirl Scouts of Kansas HeartlandHHS Booster Club ScholarshipsKansas Children's Service LeagueKansas Food Bank- Food4Kids- Finney CountyLeave a Legacy FoundationMagic Hopes Therapeutic Horsemanship ProgramMeals on WheelsMiles of SmilesRussell Child DevelopmentSalvation Army- Local ChapterSANE/SART of Finney CountySeeds of Hope- Jail MinistrySouthwest Boxing ClubWestern Kansas Child Advocacy Center
170. THE DEFENDANT OR THE ATTORNEY FOR THE DEFENDANT SHALL FILE AND OBTAIN AN ORDER OF CONTINUANCE OF ALL HEARINGS AT THE TIME THE DIVERSION APLLICATION IS SUBMITTED TO THE COUNTY ATTORNEY'S OFFICE. SAID MOTION AND ORDERS FOR CONTINUANCE SHALL BE CHARGED TO THE DEFENDANT.
172. I ACKNOWLEDGE THAT IT IS MY RESPONSIBILITY TO ENSURE THAT I APPEAR IN COURT FOR THE SCHEDULED COURT DATE OR MAKE ARRANGEMENTS TO CONTINUE THE CASE TO A DATE AFTER THE DIVERSION CONFERENCE DATE. *

     1. Yes
176. Defendant's Signature*

     /s/ First and Last Name

Leave This Blank:


178. 1. Receive an email copy of this form.
179. Email address

     This field is not part of the form submission.

180. Submit Submit and Print

* indicates a required field