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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