Employment Information

Name of Employer:
Address:
Name of Supervisor:
Supervisor's Work Telephone Number:
Your Job Title:
Describe your job duties:
How long have you worked for this employer:
Your Income:	Per
Hours per week worked:	40 OR:

Family Information

Marital Status:	Single MarriedDivorced WidowedSeparated Living with Someone
Number of Dependents:

List all persons to whom you are related by blood or marriage, residing in the county in which you were arrested:

Name	Address	Relationship

Facts of this Case

Summarize what you believe you are charged with in your own words:

Give a detailed description of the facts and circumstances that the charges are based on:

If you believe you are not guilty of all or some of these charges, please explain in your own words why you are not guilty:

Do you know how you wish to plead to these charges?

No/Need More Information/Need Advice From Attorney Before Deciding

Yes, As Follows: Guilty Not Guilty No Contest or Nolo Contendere

Please advise of any other special circumstances your attorney should know:

Do you have an alcohol or other substance abuse problem?

Have you had such a problem in the past?

Is there a history of family violence or physical abuse in your family or in your past?

Why did you come to our particular law firm seeking advice or counsel?

Do you have a court date scheduled? No Yes, As Follows:

Date: Time:

Court:	City of Lawrenceville Municipal Court Recorder's Court of Gwinnett County State Court of Gwinnett County Superior Court of Gwinnett County City of Municipal Court State Court of County Superior Court of County Other:
Have you already appeared in court on this case?	No Yes, As Follows: Preliminary Hearing Bond Hearing Arraignment Bench Trial Jury Trial I Don't Know
Do you have a written copy of the charges against you?	No Yes-Attached
Do you know your case number?	No Yes, It is as follows:
Do you know the name of the judge hearing your case?	No Yes, His/Her Name is:
Was anyone else arrested or charged in connection with the incident that resulted in your arrest ("Codefendant")?	No Yes, As Follows:
Name	Charges
Are there any witnesses to the incident resulting in your arrest?	No Yes, As Follows:
Name	Address
Are there any 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 Of Your Prospective Witnesses	Address
Name Of State's Prospective Witnesses	Address

Prior Criminal Record

(COMPLETE IN FULL EVEN IF YOU THINK THIS SECTION DOES NOT APPLY TO YOU!)

Have you ever been arrested on any charge, at any time in your life, in Gwinnett County?	No Yes, As Follows:
Date of Arrest:	Charges:
Did you go to court?	No (Explain): Yes, As Follows:
Court:	City of Lawrenceville Municipal Court Recorder's Court of Gwinnett County State Court of Gwinnett County Superior Court of Gwinnett County Other:
Case Number:
Outcome:	Pled Guilty to Charge of Pled No Contest or Nolo Contendere to Charge of Pled Not Guilty, Found Not Guilty in Trial Pled Not Guilty, Found Guilty In Trial Charges Dropped or Dismissed (EXPLAIN):
Sentence:
Are you now on probation/parole as a result of this case?	No Yes. My Probation/Parole Officer is:
Name	Telephone Number

Have you ever been arrested on any charge, at any time in your life, in any jurisdiction in the State of Georgia?	No Yes, As Follows:
Date of Arrest:	Charges:
Did you go to court?	No (Explain): Yes, As Follows:
Court:	City of Municipal Court State Court of County Superior Court of County Other:
Case Number:
Outcome:	Pled Guilty to Charge of Pled No Contest or Nolo Contendere to Charge of Pled Not Guilty, Found Not Guilty in Trial Pled Not Guilty, Found Guilty In Trial Charges Dropped or Dismissed (EXPLAIN):
Sentence:
Are you now on probation/parole as a result of this case?	No Yes. My Probation/Parole Officer is:
Name	Telephone Number
Have you ever been arrested on any charge, at any time in your life, in any other State of the U.S.A. or foreign jurisdiction?	No Yes, As Follows:
Date of Arrest:	Charges:
Did you go to court?	No (Explain): Yes, As Follows:
Court:	City of Municipal Court State Court of County Superior Court of County Other:
Case Number:
Outcome:	Pled Guilty to Charge of Pled No Contest or Nolo Contendere to Charge of Pled Not Guilty, Found Not Guilty in Trial Pled Not Guilty, Found Guilty In Trial Charges Dropped or Dismissed (EXPLAIN):
Sentence:
Are you now on probation/parole as a result of this case?	No Yes. My Probation/Parole Officer is:
Name	Telephone Number

Have you been entirely candid and truthful and provided all pertinent information asked for this questionaire?