2. Date*
   Date

   Date

3. Case Title*

   People v.

5. Case Number*
6. Court*
8. Judge*
9. Next Court Event and Date (if any)*
11. Offense Location (city, township, or village)*
12. Offense Date(s)*
14. Officer in Charge*
15. Type of Charge*
    -- Select One --District Court MisdemeanorDistrict Court Felony requesting MisdemeanorGeneral District CourtGeneral Circuit CourtOWi 3rdSpecial Unit (not capital, death, or major assault)Special Unit (with capital, death, or major assault)
17. Defense Attorney Name*
18. Defense Attorney P#*
20. Defense Attorney Phone*

    Please enter a valid phone number

21. Defense Attorney Email*

    example@example.com

23. Defense Law Firm Name*
25. Defense Attorney Address
27. Street Address*
28. Street Address Line 2
30. City*
31. State / Province*
33. Postal / Zip Code*
35. Brief Summary of the facts of the case*
37. Pending Charges
39. Count 1
41. PACC Code
42. Felony or Misdemeanor
43. Pending Count's Title
45. Count 2
47. PACC Code
48. Felony or Misdemeanor
49. Pending Count's Title
51. Count 3
53. PACC Code
54. Felony or Misdemeanor
55. Pending Count's Title
57. Count 4
59. PACC Code
60. Felony or Misdemeanor
61. Pending Count's Title
63. Count 5
65. PACC Code
66. Felony or Misdemeanor
67. Pending Count's Title
69. Sentencing Guidelines, if convicted on pending charges
71. Specific deviation result requested (required)
73. Count 1
75. PACC Code*
76. Felony or Misdemeanor*
77. Pending Count's Title*
79. Count 2
81. PACC Code
82. Felony or Misdemeanor
83. Pending Count's Title
85. Count 3
87. PACC Code
88. Felony or Misdemeanor
89. Pending Count's Title
91. Count 4
93. PACC Code
94. Felony or Misdemeanor
95. Pending Count's Title
97. Count 5
99. PACC Code
100. Felony or Misdemeanor
101. Pending Count's Title
103. Sentencing guidelines, if convicted on requested deviation
105. Defendant's efforts at rehabilitation during pendency of case, if any

     examples may include: anger management, evaluation/counseling, substance abuse evaluation, documentation as to AA NA attendance or other counseling, etc.
     
     

107. Defendant's status on date of offense*

     1. On Bond
     2. Probation

     1. Parole
     2. Other
109. Summary of relevant criminal history
111. Treatment Court, if attending

     1. None
     2. Drug Court
     3. Mental Health Court

     1. Veterans Court
     2. Other
113. Brief summary of reason for requesting deviation
115. File Upload
117. 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.
119. Electronic Signature
Leave This Blank:


121. 1. Receive an email copy of this form.
122. Email address

     This field is not part of the form submission.

123. Submit

* indicates a required field