Name
Email Address
Phone Number
Business Phone
Cellular or Pager
Address
City
State
Zip
Birth date
Have you previously been convicted of domestic violence Yes No
If yes, when
Have you been convicted of other offenses Yes No
If yes, what and when
Are you on probation or parole Yes No
If so, for what
Do you have any other pending cases
Has a temporary restraining order been issued against you Yes No
If so, when was it issued
For what reason
Has a long-term restraining order been issued against you Yes No
If so, when
What are the conditions of the order
When does the order expire
Who brought the domestic violence charge
Was anyone else arrested (including the person who brought the charge) Yes No
If so, name all persons arrested
List any witnesses to the alleged act
What statements do you remember making to the police about the events leading to the charge
Describe the events leading up to the arrest
What is your relationship with the alleged victim
Do you have any children Yes No
Are you married Yes No
Are you involved in divorce proceedings Yes No
Have you discussed the alleged domestic violence incident with anybody else Yes No
If so, with whom did you discuss it and what did you tell him or her
What is the amount of any bond you posted
Are there any special bond conditions
Were you referred by someone Yes No
If so, who
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