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Client Application

Please complete this form so we can gather information for potential clients. This form needs to be completely filled out and submitted as soon as possible. Interviews must be scheduled via phone, 574-732-2515, and completed at least two weeks prior to sentencing. If your court date is more than 30 days away, please submit your application and schedule your interview as soon as possible. Please attach charging information, police reports, and potential plea agreement.

Disclaimer: Submission of an application does not guarantee review or acceptance into the program. Applications submitted by attorneys with plea agreements including a community corrections sentence are prioritized. Please know that the final determination regarding placement into Community Corrections is made by the Court.

Name

Social Security Number

Home Phone

Other Last Names or Alias

Email

Cell Phone

Address

City

Age

State

Date of Birth

Race

Zip Code

State of Birth

Attorney Name

Attorney Phone Number

Current Offene/Pending Charge (Include IC Code)

Current Cause Number

Other Pending Cases

If yes, what for?

If yes, county & end date

If no, please explain why you did not successfuly complete Community Corrections

If yes, amount?

Present Employer

Employer Phone

Hourly Rate

Supervisor's Name

Employer Address

Hire Date

Shift

Supervisor's Phone

Please attach your plea agreement if available.

Upload File

Please attach any other documents you have.

Upload File

I understand that I must notify Cass/Pulaski Community Corrections two (2) weeks prior to sentencing to be scheduled for an evaluation. I also understand that information contained in this application may be verified by Cass/Pulaski Community Corrections through contact with various individuals or agencies.

I hereby give all parties that are outlined under IC 35-38-1-13 permission to provide a copy of my presentence report investigation to Cass/Pulaski County Community Corrections for referral purposes.

Signature

Select a date

Referral Signature

Select a date

Do I qualify for possible placement in Community Corrections Programming?

Eligibility Requirements Include But Are Not Limited To:

Residential Stability
Financial Ability to Pay Program Fees
Employment
Have had no history or escape or absconding
Have no active warrants, holds or detainers

List of Factors That Disqualify Potential Clients from Community Corrections:

Multiple convictions involving violence, weapons, or criminal sexual acts
History of escape or absconding
History of violating or being revoked from Community Corrections
Outstanding Balance owed to Community Corrections
Active warrant, hold or detainer
Substantial risk of flight, risk to victim and public safety

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Client Application

Do I qualify for possible placement in Community Corrections Programming?

Eligibility Requirements Include But Are Not Limited To:

List of Factors That Disqualify Potential Clients from Community Corrections:

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Online

Client Application

Do I qualify for possible placement in Community Corrections Programming?

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Eligibility Requirements Include But Are Not Limited To:

​

List of Factors That Disqualify Potential Clients from Community Corrections:

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