*Last Name

*Email Address

*Phone Number

*Zip

Street Address

Apt/Ste

Incident Street Address

Incident Apt/Ste

*Incident Zip

Business Phone

Cellular or Pager

Booking #

Driver’s License #

Court Date

Time

Court Name

Division/Room

Arresting/Ticketing Officer’s Name and Badge Number

City of Arrest/Citation

What were you arrested/ticketed for (include Code section)?

Have you been convicted of or ticketed for a similar crime before?
Yes  No 

If yes, what and when?

Have you been convicted of or ticketed for other offenses?
Yes  No 

If yes, what and when?

Are you on probation or parole?
Yes  No 

For what?

Do you have any other cases pending?
Yes  No 

What statements do you remember making to the police about the alleged violation?

Describe the order of events leading up to the arrest/citation

Have you discussed the alleged violation with anybody else?
Yes  No 

If so, whom did you discuss it with and what did you tell them?

Were there any witnesses to the alleged violation?
Yes  No 

If yes, provide names and contact information if known

Were any injuries or property damage caused during the incident?
Yes  No 

If yes, provide details

What is the amount of the bond you posted, if any?

Are there any special bond conditions?

Did someone refer you to this law office?
Yes  No 

Who?

Special concerns

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