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Docket Number:
NOTICE OF INTENT TO REFER TO PROGRAM
Defendant Information
TO: (Name)_____________________________ (Mailing Address)_______________________________________
(Date of Birth)_________________________ (Email Address)_________________________________________
(Offense)_____________________________ (Docket No.)__________________ (Incident No.)_____________
(Offense)_____________________________ (Docket No.)__________________ (Incident No.)_____________
I intend to refer you to the
☐
Diversion Program
☐
Tamarack Program
to resolve the offense(s) described above. If you accept this referral, you must sign this form and either:
1. meet with a Program representative at the courthouse TODAY;
or
2. con
tact the Program WITHIN SEVEN
(7) DAYS OF THE DATE OF THIS NOTICE.
You may contact the Program by telephone, mail or in person. The contact information for the Program in this
County is:
Successful resolution of your case through the Program is subject to: (1) your agreement to participate in the
Program under the terms set forth below and (2) your successful completion of the Program. If you decide not to
accept this referral, your case will proceed forward in court.
Dated
_____________________________ _______________________________________
Signature of State’s Attorney or Deputy
ACCEPTANCE OF PROGRAM REFERRAL
I hereby accept the offer of the State's Attorney to participate in the Program indicated above. I understand that if
I choose not to participate in the Program or I am found to be ineligible for the Program, I must appear in Court
whenever my case is scheduled for a hearing.
My mailing address is:
☐
The address set forth above is a correct
mailing address
for me.
☐
The address set forth above is
not
a correct mailing address.
My NEW correct mailing address is: __________________________________________________________
Home Phone: _______________ Cell Phone: _______________ Business Phone: _______________
Email Address: ___________________________________________
I agree to immediately inform the Court if my address changes. I understand that if my case is scheduled for a
Court hearing and I fail to attend the hearing, the Court may issue an arrest warrant and require bail.
Dated
_____________________________ __________________________________________________________
Signature of Defendant
Dated
_____________________________ __________________________________________________________
Signature of Parent/Guardian (if Defendant is a minor)
cc: State, Defendant, Diversion/Tamarack
200-00081 – Notice of Intent to Refer to Program (10/2019)
