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1 January 2017 1 OOFFFFIICCEE OOFF TTHHEE DDIISSTTRRIICCTT AATTTTOORRNNEEYY TH IRD judicial DISTRICT OF KANSAS M ichae l F. Kagay, Dis trict Attorne y TRAFFIC diversion APPLICATION A $ non-re fundable Applicat ion Fee must be submitted with this applicat ion. The Application Fee must be in the form of a Cashier s Check, Money Order or Attorney Trust Account - payable to t he District Attorney. NO CASH OR PERSONAL CHECKS WILL BE ACCEPTED. A copy of the front and back of the ticket M UST also be submitted wit h the application.

2 I. PERSONAL INFORMATION Last Name , First Name , Date of Birth / / Sex SSN _____ Driver s License # Driver s License State_____ P hone # E-mail_____ Ticket # Date of Ticket / / Current Address Information: Address C ity State/ Zip II. PARENTAL INFORMATION If you are under the age of 18, please list your parent or guardian inf ormat ion. Mother (Name, Address, Daytime P hone) Father (Name, Address, Daytime Phone) III. ATTO RNEY INFORMATION If you have an attorney representing you, please list their infor mation: Atto rne y (Na me, F irm, Address, P ho ne, Ema il) I hereby certify that I have answered this applicat ion trut hfully and to the best of my know ledge.

3 I also understand that any false infor mation conta ined in the application will be a basis for the revocation of any diversion agreement. Signature of Defendant _____ Date _____ TO SUBMIT THIS APPLICATION FOR CONSIDERATION IT MUST H AVE: 1. A CO PY O F THE FRONT AND BACK OF YOUR TICKET. 2. $ NON-REFUNDABLE CASHIER S CHECK, MO NEY O RDER, OR ATTORNEY TRUST ACCOUNT CH ECK.