Court Fines/Fees Questionnaire
The information provided in this questionnaire is for the sole use of The Almond Connection and will not be shared with any person or organization without expressed, written permission from the applicant and The Almond Connection. Eligible applicants will have their Guilford County court fines/fees paid (full or partial) and be contacted regarding any upcoming court date and whether transportation is needed on their court date. You are expected to be at court on the dates necessary. Please answer the following questions to the best of your ability. Fill out as much as possible, not all fields are required:
Today's Date
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Month
-
Day
Year
Date
Full Legal Name
First Name
Middle Name
Last Name
Suffix
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Cell Phone Number
Please enter a valid phone number.
Birth Date
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Month
-
Day
Year
Date
Valid Driver's License Number or State ID Number
Which organization and case manager referred you?
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What fines and fees are owed to the court? Please list them all individually.
What are your specific charges? Please write your case number(s)?
Do you have adequate transportation to court?
Yes
No - I will need help with transportation
Can you commit to being present for your court day(s)?
Yes
No
Other
Do you have an attorney? If yes, please write their name? If not, do you plan on getting a private attorney or public defender?
Do you need help with a prior record expungement?
Yes
No
Are you employed? If yes, please write your employer's name. If not, would you like to be connected to resources that can assist you with employment?
Are you working through any addictions? If yes, are you getting help? If not, would you like to be connected to resources that can help?
Do you have any mental health or other medical needs? Are there any medications you need? Would you like to be connected to resources that can help?
Do you have children? If yes, do you have custody of them? What are their ages?
Do you have housing (for your children too)?
Yes
No - I need help finding housing
Do you have supportive family members and/or a support system that can help you? Please share their name and phone number with us, so we may connect and coordinate with them.
In your current situation,what are your goals and how do you plan to attain them?
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What is your expectation of The Almond Connection?
Thank you for your responses. We hope to assist you in the best way possible. We will respond to you shortly.
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