Date:
Source:
Attorney:
Name:
Address:
City/State: Zip:
Telephone No: (H) (W)
Social Security No:
Date of Birth: (Client)
Please Select all that apply:
Assault
DWI
Susp. License
Traffic (Other)
Possession (Misd)
Mideamenor (Other)
Felony (Other)
Juvenille
Administrative

Details of Present Charge(s):

Did Client Supply Charging Papers? Yes No

Does Client Contend Factual Errors in Charging Papers? Yes No
If Yes, describe:

Jurisdiction: City/County:

Released On Own Recog? Yes No
Bail Set? $

Witness Names & Addresses:
Witness #1
Name:
Address:
City/State: Zip:
Witness #2
Name:
Address:
City/State: Zip:
Witness #3
Name:
Address:
City/State: Zip:

Co-Defendants & Addresses:

Co-Defendant #1
Name:
Address:
City/State: Zip:
Co-Defendant #2
Name:
Address:
City/State: Zip:
Co-Defendant #3
Name:
Address:
City/State: Zip:

Prior Charges or Convictions? Yes No
Charge Date Disposition
Charge Date Disposition
On Probation Presently? Yes No
If Yes, Supervised/Unsupervised Original Length of Probation # of months left
Probation Officer’s Name: Phone #:

Mitigation Information

Occupation
Employer Phone #
Supervisor Years at Job
Highest Level of Education School
Military Service Yes No Branch/Base: Honorable Discharge? Yes No
Memberships: Church Clubs
Charitable Work?

Other Extracurricular Activities (youth, sports, organizations, PTA ,etc):

Children? Yes No Names & Ages
Married? Yes No Name of Wife and Length of Marriage
Presently Under Psychiatric Care? Yes No
Presently Enrolled in AA or NA or Classes? Yes No

Attorneys’ Fee

Fee Quoted $ (consider all pending charges, priors, need for evidentiary motions & prelim hearings)

Payment Arrangement

Deposit Amount $ Date Rec’d Cash Check Money Order

Payment Schedule Date:

1. Date: Amount: $
2. Date: Amount: $
3. Date: Amount: $

Client Follow-Up Required:

Advise of Names & Addresses of Co-Defendants or Witnesses
Enroll in Alcohol Ed. at:
Provide Arrest Records for Pending Cases
Provide Letter of Recommendation from Employer, Church, etc.
Obtain Out of State Driving Record
Satisfy Unpaid Fine Prior to Trial
Other:

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