NICC Application

Northeast Indiana Community Corrections Application

*You must fill out the entire application to the best of your knowledge or you will be denied. *

*If you falsify information and are placed onto NICC because of that information, your placement will be revoked*

Name*

Date

Hour MinutesAM/PM Option

1. Judge*

2. Defense Attorney*

3. Cause Number*

4. Offense*

5. Are you here because of a probation violation?*

YESNO

a. If yes, how did you violate probation?*

6. Your next court date or report date*

Court dateReport date

Next Court Date / Report Date*

Date

7. Plea/Sentence (time to serve)*

8. Are you currently on probation or parole?*

YESNO

Will you be?*

YESNO

9. Victim (if any)*

10. Are you within the United States legally?*

11. Are you a veteran?*

YESNO

If yes, which branch(s)*

12. Print any co-defendants you have for the above cases*

13. Print any enemies you have*

14. Other Pending Cases (Offense / Cause Number or County)

a.*

b.*

15. Education Level and Year completed*

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Northeast Indiana Community Corrections Application

Accommodations *** Must have running water and electricity ***

16. Current Address*

17. What address will you live at while on Community Corrections (if different than current)*

18. Does the residence in which you will live while on Community Corrections have:

a. Electricity*

YESNO

b. Running water to drink, shower with, and carry away waste*

YESNO

19. Do you intend to transfer to a different County?*

YESNO

a. What County?*

20. Do you intend to do your supervision at a Transitional/Recovery House?*

YESNO

a. Where? (Name/Address)*

21. Print everyone’s first and last name that stays overnight in the same residence as you that is 18 years or older. Specify their relationship to you.

a.*

b.

c.

d.

e.

f.

g.

h.

22. Land Line Phone*

Cell Phone*

23. Email address*

example@example.com

24. What is the status of your driver’s license?*

25. What is your drivers’ license or state ID number?*

26. Date of Birth*

Date

Ethnicity*

Gender*

27. Social Security Number - You may be contacted to provide this information. The data is not collected here.

28. Do you pay or owe child support (How much?)*

29. Do you pay or owe restitution (How much?)*

30. Are you required by law to register as a Sex Offender?*

YESNO

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Northeast Indiana Community Corrections Application

a. If yes, how often?*

31. Are you required by law to register as a Violent Offender?*

YESNO

b. If yes, how often?*

32. Protective Order(s) (If yes, then with whom?)*

33. Have you ever Escaped, Failed to Return to Lawful Detention, or Failed to Appear?*

34. Have you been revoked from previous community-based supervision in the past?(Probation, Parole, Community Corrections)*

YESNO

35. If yes, when/where?*

Employment - Your employment is subject for approval

36. Are you physically fit to work?*

YESNO

37. Are you mentally fit to work?*

YESNO

38. Have you applied for or are you currently awaiting a decision for disability?*

YESNO

39. Do you plan on applying for disability?*

YESNO

40. Employer*

a. Address of where you work*

b. Travel time to work from residence*

c. Do you leave the jobsite for work purposes?*

YESNO

d. Shift/Hours*

Pay Rate*

41. Employer Notified about your current offense?*

YESNO

a. Is a supervisor with you or at the worksite while you are working?*

YESNO

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Northeast Indiana Community Corrections Application

i. Is your supervisor a family member?*

YESNO

42. What employment will not be approved:

a. Any employment in which you enter an occupied private residence

b. Any employment that is more than 60 miles from your residence

c. Any employment that takes you more than 60 minutes to reach

d. Any employment that switches locations more than 5 times a day

e. Working for a relative or significant other

f. Any employment that you cannot get a pay stub from

g. Self-employment in which you do not have another person with you to verify you were working.

Initial Costs for Home Detention:

Working over 20 hours a week: $75 intake fee (nonrefundable) + $25 drug test + $101.50 first week= $201.50

Not working or on disability: $75 intake fee (nonrefundable)+ $25 drug test + $435 first month = $535

Community Transition Program (early release from prison): $0

Transferring to another county: $150 (nonrefundable)

Initial Costs for NICC Work Release:

Working over 20 hours a week: $75 intake fee (nonrefundable) + $25 drug test + $35 bedding fee + $175 the first week of supervision fees = $310

Not working: $75 intake fee (nonrefundable) + $25 drug test + $35 bedding fee + $350 first two weeks of supervision fees = $485

*The weekly fees for Work Release are a minimum of $175 up to a maximum of 25% of your gross, whichever is greater. *

43. If unemployed, how will you pay your Community Corrections Fees?

Do not write that you will find a job, N/A, are currently in prison/jail, or CTP.*

44. Current (Substance Abuse or Mental Health / Agency)*

45. Previous (Substance Abuse or Mental Health / Agency / Year Attended)*

***Applicants will need to call NICC to verify this application was received and schedule an interview date. If the applicant waits until his/her report date, that person will most likely have to serve their sentence in jail/prison.***

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Signature of applicant*

Application for Northeast Indiana Community Corrections

Court Information

Treatment