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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