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2. In the matter of,
3. Full Name*
5. Cochise County Adult Diversion Program
6. Case #:*
8. Adult Diversion Program Obligations

   The following is a list of obligations that you must understand before you can make an application for the Cochise County Attorney’s Adult Diversion Program. These conditions will also apply if you are accepted into the Program.

   • Involvement in the Program is voluntary. I may withdraw from consideration or participation in the Program at any time and understand that I will then return to Court for this offense.
   • Truthfulness is important in determining acceptance into the Program. All information given in the application and during the interview will be reviewed and verified. Any intentional falsifications or omissions may result in rejection or revocation. It should also be understood that during diversion consideration and/or participation there is no confidentiality of information.
   • As a condition entering the Adult Diversion Program, I will enter a Conditional Plea. Should I not, for any reason, satisfactorily complete the Program, or should prosecution be resumed against me, the State intends to enforce the plea against me in all future court proceedings.
   • Should I be rejected from the Program, information I may have given or the fact that I applied would not be used against me by the prosecutor in the case but may be used for impeachment purposes if I tell a different story in court.
   • I must not leave the State without first receiving consent from this office and from the court through my attorney.
   • I must not knowingly associate with persons who violate the law, and I must not violate the law again or I may be prosecuted for both the new offense and for this offense.
   • I must cooperate with and report to this office as requested. I must meet all of the conditions of my individual program, and I must also cooperate with any agency to which I am referred.
   • I understand that failure to fulfill any of these obligations may be considered sufficient cause for my rejection or revocation by the Cochise County Attorney’s Adult Diversion Program, and that I may then go to court for this offense.
   • I have not previously been convicted of a Serious offense as defined in A.R.S. §13-706.
   • I have not previously been convicted of a Dangerous offense as defined in A.R.S. §13-105.
   • I have not previously been convicted of a Dangerous Crime Against Children as defined in A.R.S. §13-705.
10. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
12. Electronic Signature

16. All questions must be answered completely; if the question does not apply, mark N/A which means not applicable. Be ACCURATE, COMPLETE and TRUTHFUL. 

18. Full Name (First, Middle, Last)*
20. Address (Street, City, State and Zip)*
22. Home Phone
23. Work Phone
24. Mobile
26. Primary Email Address
28. If unable to reach me contact:
30. Name of Contact
31. Relationship
33. Contact Address
34. Contact Phone Number
36. Personal Data
38. Age
39. Place of Birth
40. Gender
42. Height
43. Weight
44. Hair
45. Eyes
47. Marital History
49. Marital Status

    1. Single
    2. Married
    3. Divorced

    1. Separated
    2. Widowed
50. Present Spouse
51. Maiden Name
53. Spouse Age
54. Spouse Address
55. Nature of Relationship

    1. Good
    2. Adequate
    3. Poor
57. Children (Full Name, Gender, Age and Address)

    Indicate the relationship to you (you and your spouse's children, your children form a previous marriage, your spouse's children from a previous marriage, foster children.)

59. Family History
61. Father Name
62. Father Age
63. Father Place of Birth
65. Father Address

    Street, City, State

66. Father Occupation
68. Mother Name
69. Mother Age
70. Mother Place of Birth
72. Mother Address

    Street, City, State

73. Mother Occupation
75. Stepparent Name
76. Stepparent Age
77. Stepparent Place of Birth
79. Stepparent Address

    Street, City, State

80. Stepparent Occupation
82. Brothers / Sisters

    Name(s), gender, age(s), address

84. Current relationship with Father

    1. Good
    2. Adequate
    3. Indifferent

    1. Bad
    2. None
85. Current relationship with Mother

    1. Good
    2. Adequate
    3. Indifferent

    1. Bad
    2. None
87. Current relationship with siblings

    1. Good
    2. Adequate
    3. Indifferent

    1. Bad
    2. None
88. Are your parent aware of your present offense?

    1. Yes
    2. No
90. Education
92. Do you have a high school education?

    1. Yes
    2. No
    3. GED
93. Highest grade completed

    1. 8th of less
    2. 9th
    3. 10th
    4. 11th
    5. 12th

    1. College 1 year
    2. College 2 years
    3. College 3 years
    4. College 4 years or more
95. School Information (Name, Address and dates attended/diploma)

    List any high schools, colleges, business or trade schools attended starting with the most recent

97. Housing
99. With whom are you living at the present time?

    1. Alone
    2. with parents

    1. spouse
    2. friend
100. Name of person you are living with
102. Amount of rent/mortgage $
103. How long have you resided at the present address?
105. How long have you resided in Cochise County?
106. How many places have you lived in the past year?
108. Employment History
110. Employment Status

     1. Employed
     2. Unemployed
111. Occupation
112. Are you satisfied with your present employment?

     1. Yes
     2. No
114. Employment Information (Employer, Address, Type of Work, From - To)

     Starting with your present employment, list your employment for the last two years. If unemployed, start with your most recent employment.

116. Fixed Income and Expenses
118. Your Income

     Net Monthly Income AFTER deductions

119. Spouse Income

     Net Monthly Income AFTER deductions

121. Child Support
122. Interest/Dividends
123. Other
125. Fixed Monthly Expenses
127. Mortgage or Rent
128. Utilities (Average)
129. Car Payment
131. Insurance
132. Other
134. Previous Involvement with Law Enforcement
136. Have you ever been arrested before as an adult?

     1. Yes
     2. No
137. If so, charge/s:
139. Where?
140. Date
141. Disposition
143. Do you have any outstanding tickets?

     1. Yes
     2. No
144. If so, citation/s:
146. Where was Citation?
147. Date of Citation
149. Physical and Emotional Health
151. Health Status

     1. Excellent
     2. Good
     3. Poor
152. Explain

     Please list any disabilities, chronic illness or problems

154. Are you presently under a doctor's care?

     1. Yes
     2. No
155. Have you ever had psychiatric or other mental health?

     1. Yes
     2. No
157. Alcohol and Drug Use
159. Describe your drinking habits - past and present
161. Have you ever used marijuana, narcotics or dangerous drugs of any kind?

     1. Yes
     2. No
162. Is so, please describe drug use
164. Military History
166. Branch of Service
167. Date Entered
168. Date of Separation
170. Type / Discharge
171. Are you eligible for G.I. benefits?

     1. Yes
     2. No
173. Instruction

     I certify that the information I have provided is truthful and accurate, and I understand that providing the Adult Diversion Program with inaccurate and dishonest information may be sufficient cause to reject my application or later revoke me from the Diversion Program.

175. Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
177. Electronic Signature
179. Social History

     Write a short story of your life giving information about your home life.

Leave This Blank:


181. 1. Receive an email copy of this form.
182. Email address

     This field is not part of the form submission.

183. Submit

* indicates a required field