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VILLAGE OF CALEDONIA TO: Appellants for Sex Offender (Village of Caledonia)

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VILLAGE OF CALEDONIA
TO: Appellants for Sex Offender Residency Appeal
The appellants for a Sex Offender Residency Appeal must submit a complete application before a hearing can
be scheduled. Please read the application carefully and thoroughly to ensure it is completed properly.
For your application complete all checkmarks listed and include requested attachments:
SECTION A – Personal Information; Caledonia Address; Citation information (date and contact name);
Property Type (If rental please attach acknowledgement letter from the property owner – this includes
significant others who may own the home); Age, name and relationship of those you’ll be living with.
SECTION B – List every sexual offense on your conviction record. If you have been convicted of four or
more sexual offenses, attach extra sheets listing those offenses. Attach copies of Judgment of
Conviction (Adjudication) and copies of the official complaints/ police reports.
SECTION C – List all previous criminal convictions (exclude juvenile offenses). If more space is needed,
attach an extra sheet.
SECTION D – List the names of any treatment programs you have completed and that are ongoing and
attach a document proving that you have completed or are attending, or answer “None” if you
completed no programs. (IF NO RECORD IS AVAILABLE, PLEASE SUBMIT A TYPED RESPONSE
INDICATING WHY YOU WERE NOT ABLE TO OBTAIN THE DOCUMENTS. INCLUDE A NAME AND PHONE
NUMBER OF THE PERSON YOU SPOKE TO WHO TOLD YOU THE RECORDS ARE NOT AVAILABLE.)
SECTION E – Please provide the name and phone number of the following people/groups that will
support you move to Caledonia.
SECTION F – Sign and date the application
1
VILLAGE OF CALEDONIA SEX OFFENDER
RESIDENCY BOARD APPEAL APPLICATION
You must type or print answers to every
question on this appeal application.
SECTION A
PERSONAL INFORMATION
Full name:
Current address:
Date of birth:
Telephone # :( ) -
Age/Name/Relationship of those who you live with now:
To what address do you wish to move?
Have you received a citation/or been in contact with the Village of Caledonia law enforcement regarding this property?
If yes, provide a date and contact name
Is this a rental property (or a property you DO NOT own)?
If yes
attach a letter from the property owner which
shows that he/she is willing to rent to you and knows you are a registered sex offender. Your appeal will not be heard
until you provide such proof.
Age/Name/Relationship of those who you plan to live with:
Name and Phone Number of your Dep’t of Corrections Agent, if applicable:
SECTION B
SEXUAL OFFENSE(S)
List every sexual offense on your conviction (adjudication) record and answer the following questions:
Attach copies of Judgment of Conviction (Adjudication) and copies of the official complaints/ police reports.
SEXUAL OFFENSE #1 Conviction type: ADULT JUVENILE
Offense Degree (circle one): 1
st
2
nd
3
rd
4
th
Offense:
Offense Date:
Victim’s age:
Conviction Date:
Sentence:
In what county?
Time served:
Are you currently under supervision with the Department of Corrections for this offense?
How do you feel this sexual crime affected your victim? (Do not identify victim)
In your own words describe what you did that resulted in charges against you and who the victim was to you (do not
identity victim by name).
SEXUAL OFFENSE #2 Conviction type: ADULT JUVENILE
Offense Degree (circle one): 1
st
2
nd
3
rd
4
th
Offense:
Offense Date: Conviction Date: In what county?
Victim’s age: Sentence: Time served:
Are you currently under supervision with the Department of Corrections for this offense?
How do you feel this sexual crime affected your victim? (Do not identify victim)
In your own words describe what you did that resulted in charges against you and who the victim was to you (do not
identity victim by name).
For Office Use Only:
Date Received:
Received by: (Initials)
Application Complete:
Applicant Notified:
Application fee ($25.00) Paid:
2
SEXUAL OFFENSE #3 Conviction type: ADULT JUVENILE
Offense Degree (circle one): 1
st
2
nd
3
rd
4
th
Offense:
Offense Date: Conviction Date: In what county?
Victim’s age: Sentence: Time served:
Are you currently under supervision with the Department of Corrections for this offense?
How do you feel this sexual crime affected your victim? (Do not identify victim)
In your own words describe what you did that resulted in charges against you and who the victim was to you (do not
identity victim by name).
____Check here if you have been convicted of four or more sexual offenses, attach extra sheets listing those offenses
____Check here if you have had offenses read in at conviction/adjudication of a crime, attach list/dates.
Attach copies of Judgment of Conviction (Adjudication) and copies of the official complaints/ police reports.
SECTION C
CRIMINAL HISTORY
Are you currently incarcerated? If so, when is your expected release date?
List all previous criminal convictions below, including date and location of each offense (attach extra sheets, if needed):
CRIME (Exclude Juvenile Offenses) OFFENSE YEAR IN WHAT CITY/STATE DID THIS OCCUR?
1.
2.
3.
4.
SECTION D
COMPLETED AND ONGOING TREATMENT PROGRAMS (if applicable)
(This confidential part of your appeal will only be available to the Board and not be available to the public)
List the names of any treatment programs you have completed and that are ongoing and attach a document proving
that you have completed or are attending that treatment program, or answer “None” if you completed no programs.
THE BOARD WILL ASSUME YOU HAVE NOT COMPLETED A TREATMENT PROGRAM UNLESS YOU PROVIDE A DOCUMENT
WHICH PROVES YOU HAVE COMPLETED THE TREATMENT PROGRAM AND YOUR DOC AGENT SIGNS BELOW. IF NO
RECORD IS AVAILABLE, PLEASE SUBMIT A TYPED RESPONSE INDICATING WHY YOU WERE NOT ABLE TO OBTAIN THE
DOCUMENTS.
SUBJECT NAME(S) AND DATES OF COMPLETED/ONGOING TREATMENT PROGRAM(S)
Sex Offender
Anger
Alcohol
Drugs
3
Other
SECTION E
COMMUNITY TIES AND SUPPORT
Identify by name which of the following people or groups will support you if you move to Caledonia. Please provide a
contact number for the individuals/support group.
NETWORK NAMES OF AND RELATIONSHIP TO YOU OF SUPPORTING PEOPLE/GROUPS/PHONE NUMBERS
Family
Work
Church
Friends
Other Support
SECTION F
APPELLANT’S SIGNATURE
BY SIGNING BELOW, I HEREBY CERTIFY THAT ALL STATEMENTS MADE ON THIS APPEAL FORM ARE TRUE AND COMPLETE. I
UNDERSTAND THAT ANY OMISSIONS OR UNTRUTHFUL STATEMENTS WILL BE GROUNDS FOR DENIAL OF MY APPEAL.
FURTHERMORE, I AUTHORIZE THE VILLAGE OF CALEDONIA TO CONDUCT A CRIMINAL
BACKGROUND CHECK AND USE ANY
INFORMATION OBTAINED THEREFROM AT MY HEARING. I HOLD HARMLESS AND INDEMNIFY VILLAGE OF CALEDONIA, ITS
OFFICERS,
AGENTS AND EMPLOYEES, AND ANY PERSONS PROVIDING THE INFORMATION, FROM ANY LIABILITY R
ELATED TO PERFORMING THE
BACKGROUND CHECK.
Appellant’s Signature: Date:
RETURN THIS COMPLETED APPEAL TO: VILLAGE OF CALEDONIA, 5043 CHESTER LANE, RACINE, WI 53402.
YOU WILL BE NOTIFIED OF THE DATE AND TIME OF YOUR APPEAL HEARING BEFORE THE CALEDONIA SEX OFFENDER RESIDENCY
BOARD, WHICH MAY BE 30-45 DAYS AFTER RECEIPT OF YOUR APPEAL AND YOUR APPLICATION IS COMPLETE.
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VILLAGE OF CALEDONIA TO: Appellants for Sex Offender (Village of Caledonia)

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Completed 20 July 2020

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