Form Center

2. Contact Information

   Brian M McIntrye
   Cochise County Attorney
   Telephone No.: (520)432-8700
   Fax No.: (520)432-8778

4. Instruction

   Complete as directed, (Failure to report can result in revocation from the program,)

6. Name (First, MI, Last)
7. Email
9. Address (Street, City, State and Zip)
10. Phone Number
12. I Live:

    1. Alone
    2. With Parents

    1. Spouse
    2. Friend
13. Name of Person You Live With
15. Means of Transportation

    1. Car
    2. Bus
    3. Motorcycle

    1. Bicycle
    2. Other
16. Other Means of Transportation
18. I am reporting for the month of
20. I am / am not employed. Place:
22. Type of work I am doing
24. Earnings $

    Note Per Hour/Week/Month

26. Have you had any contact with law enforcement in the last month?

    1. Yes
    2. No
27. Have you had any problems/difficulties during the past month?

    1. Yes
    2. No
29. Describe Details
31. Who is your Diversion Specialist?

    1. Krist-Anah Watkins

    1. Monica McCall
32. Are you currently enrolled in school?

    1. Yes

    1. No
34. How many community service hours have you completed in the last month?
35. Have you received a summons in the last 30 days?

    1. Yes

    1. No
37. During the last month have you been named as a defendant in any criminal case?

    1. Yes

    1. No
38. During the last month month have you appeared in court for any reason?

    1. Yes

    1. No
40. Please list your case manager for treatment.
42. Have you made a payment on restitution and/or supervision fee?

    1. Yes

    1. No

    Payments Are Now Exclusively Accepted On-Line

    • Make a  Payment
43. If not, why not?
45. 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.
47. Electronic Signature
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field