CRIMINAL QUESTIONNAIRE - Family Law Gwinnett County
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: |
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|Name of Supervisor: |Supervisor’s phone number: |
|How long have you worked |What is your income: $______________ |
|for this employer? |Weekly / Bi-weekly / Monthly |
FAMILY INFORMATION
|What is your marital status? |Do you have any dependants? |
|( ) Single ( ) Married ( ) Divorced |( ) Yes ( ) No |
|( ) Widowed ( ) Separated ( ) Other |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 |
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|FACTS OF THIS CASE |
|In your own words, summarize what you believe you are charged with: |
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|Give a detailed description of the facts and circumstances that the charges are based on: |
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|If you believe you are innocent of all or some of these charges, in your own words, please explain why you are not guilty: |
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|Please advise of any special circumstances your attorney should know about: |
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|How do you wish to plea to these charges? |( ) Guilty ( ) Not Guilty |
|( ) need advice from attorney before deciding. |( ) 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 |( ) Preliminary ( ) Bond |
|( ) Yes, as follows: |( ) Arraignment ( ) Jury Trial |
| |( ) Bench Trial ( ) Not sure |
|Was anyone else arrested or charged in connection with the incident |( ) No |
|that resulted in your arrest? |( ) Yes, as follows: |
|NAME |CHARGES |
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|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 |
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PRIOR CRIMINAL RECORD
|Have you ever been arrested on any charge at any time in your life in |( ) No ( ) Yes, date of arrest ___________ |
|Gwinnett County? | |
|If yes, explain: | |
|Have you ever been arrested on any charge at any time in your life in |What county ___________________________ |
|any other county in Georgia? ( ) No ( ) Yes |Charges _______________________________ |
|What was the disposition/outcome of the case? |Sentence (if applicable): _________________ |
|( ) 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): | |
|Are you now on probation as a result of this case? ( ) No |If so, provide Probation Officer’s name and number: |
|( ) Yes |______________________________ |
|Have you ever been arrested on any charge, at any time in your life, |Date of Arrest: _________________________ |
|in any other state of the USA or Foreign jurisdiction? ( ) No ( |Charges: ______________________________ |
|) Yes | |
|What was the disposition/outcome of the case? |Sentence (if applicable): _________________ |
|( ) 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): | |
***Please complete and attach form to be emailed to: chrisadams@.
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