Criminal Questionnaire

CRIMINAL QUESTIONNAIRE

Your full name: / Today’s Date:
List any other names you go by or have gone by in the past: / Current address: ______
Home number: / How long have you been at this address _____
Cell number: / Date of Birth:
Work number: / Social Security No.:
Other number: / Email:

EMPLOYMENT INFORMATION

Name and address of employer: / Your job title and description:
Name of Supervisor: / Supervisor’s phone number:
How long have you worked
for this employer? / What is your income: $______
Weekly / Bi-weekly / Monthly

FAMILY INFORMATION

What is your marital status?
( ) Single ( ) Married ( ) Divorced
( ) Widowed ( ) Separated ( ) Other / Do you have any dependants?
( ) Yes ( ) No
If yes, how many?
List below anyone to whom you are related to by blood or marriage, residing in the county in which you were arrested:
NAME ADDRESS RELATIONSHIP
FACTS OF THIS CASE
In your own words, summarize what you believe you are charged with:
Give a detailed description of the facts and circumstances that the charges are based on:
If you believe you are innocent of all or some of these charges, in your own words, please explain why you are not guilty:
Please advise of any special circumstances your attorney should know about:
How do you wish to plea to these charges?
( ) need advice from attorney before deciding. / ( ) Guilty ( ) Not Guilty
( ) No Contest / Nolo Contendere
Do you have an alcohol or other substance abuse problem? / ( ) Yes
( ) No
Have you had such a problem in the past? / ( ) Yes ( ) No
Is there a family history of violence or physical abuse in your past? / ( ) Yes
( ) No
Do you have a Court date scheduled? / ( ) Yes, when: ______
( ) No
In what County: / ( ) Municipal ( ) State
( ) Recorder’s ( ) Superior
Have you already appeared in court on this case? ( ) No ( ) Yes, as follows: / ( ) Preliminary ( ) Bond
( ) Arraignment ( ) Jury Trial
( ) Bench Trial ( ) Not sure
Was anyone else arrested or charged in connection with the incident that resulted in your arrest? / ( ) No
( ) Yes, as follows:
NAME / CHARGES
Are there any witnesses to the incident and/or witnesses who have knowledge of facts that would be useful or important to bring out in your defense or which the State’s Attorney might call against you? ( ) No ( ) Yes, as follows
NAME / ADDRESS

PRIOR CRIMINAL RECORD

Have you ever been arrested on any charge at any time in your life in Gwinnett County? / ( ) No ( ) Yes, date of arrest ______
If yes, explain:
Have you ever been arrested on any charge at any time in your life in any other county in Georgia? ( ) No ( ) Yes / What county ______
Charges ______
What was the disposition/outcome of the case?
( ) Pled guilty to the charge of ______
( ) Pled No Contest/Nolo Contendere to the
charge of ______
( ) Pled Not Guilty, found Not Guilty in Trial.
( ) Pled Not Guilty, found Guilty in Trial.
( ) Charges dropped or dismissed (explain): / Sentence (if applicable): ______
______
______
______
______
______
Are you now on probation as a result of this case? ( ) No ( ) Yes / If so, provide Probation Officer’s name and number: ______
Have you ever been arrested on any charge, at any time in your life, in any other state of the USA or Foreign jurisdiction? ( ) No ( ) Yes / Date of Arrest: ______
Charges: ______
What was the disposition/outcome of the case?
( ) Pled guilty to the charge of ______
( ) Pled No Contest/Nolo Contendere to the
charge of ______
( ) Pled Not Guilty, found Not Guilty in Trial.
( ) Pled Not Guilty, found Guilty in Trial.
( ) Charges dropped or dismissed (explain): / Sentence (if applicable): ______
______
______
______
______
______

***Please complete and attach form to be emailed to: .