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Case number: __________________________________________________________________
Date crime committed: _____________________ Date sentenced: ____________________
Initial charge: __________________________________________________________________
Final charge: ___________________________________________________________________
Title of court: ______________________________ Parish of court: ___________________
Plea:
□ Guilty □ Not Guilty □ Nolo Contendre □ Other ________________________
Disposition (check all that apply):
□ Adjudicated Guilty □ Adjudicated Not Guilty
□ Probation Expired □ Shock probation □ Incarceration: __________ term
□ Deferred Adjudication □ Deferred Prosecution □ Restitution Ordered
□
Community Service Ordered
Case number: __________________________________________________________________
Date crime committed: _____________________ Date sentenced: ____________________
Initial charge: __________________________________________________________________
Final charge: ___________________________________________________________________
Title of court: ______________________________ Parish of court: ___________________
Plea:
□ Guilty □ Not Guilty □ Nolo Contendre □ Other ________________________
Disposition (check all that apply):
□ Adjudicated Guilty □ Adjudicated Not Guilty
□ Probation Expired □ Shock probation □ Incarceration: __________ term
□ Deferred Adjudication □ Deferred Prosecution □ Restitution Ordered
□
Community Service Ordered
9. Attach a copy of all court minutes detailing the offense, the conviction, any related order, and
the penalties imposed.
10. Attach a letter from your probation or parole office either verifying your probation or parole
has been terminated or verifying the date upon which your probation or parole ends.
Regarding community supervision, parole, or probation:
Have you been released from any of the above:
□ Yes □ No
Have you ever violated the terms of any of the above:
□ Yes □ No Release Date: ________
Have you had your parole, community supervision or probation revoked:
□ Yes □ No
Date of Revocation: ___________________________________________________________
Explanation of circumstances leading to revocation and changes made to your sentence, if any:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
9071 INTERLINE AVE
BATON ROUGE, LA 70809
(225) 925-1923 1-800-821-4529 FAX (225) 925-4501
www.lrec.gov email: info@lrec.gov
