Judicial Diversion

IN THE CRIMINAL/CIRCUIT COURT FOR ________________________________COUNTY, TENNESSEE Case Number: _______________________________ Count # _________ Counsel for the State: ___________________________________________ Judicial District: _____________ Judicial Division: ___________________ Counsel for the Defendant:________________________________________ State of Tennessee Retained Pub Def Appt Private Atty Appt vs. Counsel Waived Pro Se Defendant: __________________________________ Alias: _________________________________ Date of Birth: ______________ Sex: ___________ Race: ___________________ SSN: ________________________ Relationship to Victim: __________________________ Victim's Age: __________ State ID #: _____________________ County Offender ID # (if applicable): _______________________ State Control #: __________________________ Arrest Date: _____________________ Indictment Filing Date: _____________________ ORDER OF DEFERRAL (JUDICIAL DIVERSION) On the ____________ day of ____________________________, 20___________, the defendant: Original Amended Corrected Pled Guilty Was Found Guilty By: Jury Verdict Bench Trial Pled Nolo Contendere Indictment: Class (circle one) 1st A B C D E Felony Misdemeanor Indicted Offense Name AND TCA §: _____________________________________________________________ Amended Offense Name AND TCA §:____________________________________________________________ Offense Date: ___________________________ County of Offense: ________________________________ Deferred Offense Name AND TCA §:_____________________________________________________________ Deferred Offense: Class (circle one) A B C D E Felony Misdemeanor Upon review of the case, the court finds the facts stated above as well as the following (For Item 3, Check ONE Of The Two Boxes): 1. The defendant is eligible for deferral of the prosecution pursuant to Tennessee Code Annotated section (T.C.A.) 40-35-313; 2. The Tennessee Bureau of Investigation has certified (per attached certificate) that the defendant does not have a prior felony or Class A misdemeanor conviction; 3. The defendant was not charged with a violation of a criminal statute the elements of which constitute abuse, neglect or misappropriation of the property of a vulnerable person as defined in Title 68, Chapter 11, Part 10; OR The defendant agrees without contest or any further notice or hearing that the defendant's name shall be permanently placed on the registry governed by Title 68, Chapter 11, Part 10, whereupon a copy of this order shall be forwarded by the clerk to the department of health; 4. The defendant consents to T.C.A. 40-35-313 deferral, as evidenced by the defendant's signature below; AND 5. The defendant should be granted a deferral of charges pursuant to T.C.A. 40-35-313. It is, therefore, ORDERED that the prosecution in this case is deferred pursuant to T.C.A. 40-35-313, and the defendant is placed on probation. The terms and conditions ordered by this court apply to the defendant's probation and are incorporated herein by reference thereto. Probation Term: Total Length _____________________ Beginning Date ___________________ Ending Date ___________________ Supervised Unsupervised Supervising Entity (unless otherwise provided to the defendant by the court): Name ________________________________________________________________ Phone Number_________________________ Address ___________________________________________________________________________________________ Defendant's Contact Information (unless otherwise provided to the probation officer by the court): Phone Number ______________________________________ Address _________________________________________________________________________________________________________________________________ Costs $_________ Sex Offender Tax (39-13-709) $_________ Sex Offender Fine (40-24-108) $_________ Drug Testing Fee (39-17-420) $_________ Treatment Expenses (40-35-313) $_________ Supervision Fees (40-35-313) $_________ Other: ________________________ ________________________________________ ________________________________________ Concurrent with: Restitution Victim Name _________________________ Pretrial Jail Credit Period(s): From _________ to _________ From _________ to _________ From _________ to _________ From _________ to _________ ____________________ Consecutive to: Address ______________________________ _____________________________________ Total Amount $ ________ Per Month $ __________ _____________________________________________ Defendant _____________________________________________ JUDGE'S NAME _____________________________________________ Counsel for the Defendant ENTER this the _________ day of __________________________, 20_____. _______________________________________________________________ JUDGE'S SIGNATURE _______________________________________________________________ Counsel for the State of Tennessee American LegalNet, Inc. www.FormsWorkFlow.com Rev. 4/1/13