Montgomery County, KS

I declare, verify, certify, or state under the penalty of perjury under the laws of the State of Kansas, that I have personally read or have had read to me the above application for Diversion and responses thereto and that all information contained in the forgoing application for Diversion, including but not limited to my listing of previous criminal record is true and correct. I understand that is any of this information is not true and correct, this will be a basis for denial or revocation of Diversion. I agree that if an undisclosed criminal offense or DUI is discovered after Diversion has been granted, a criminal justice report, KBI report, Police Department or Sheriff's Office report, and or Department of Revenue report may be admitted as evidence in any court, without foundation, to prove prior traffic or criminal offenses for the purpose of revocation of Diversion in this matter.

I hereby authorize the District Attorney's Office to release any information in the District Attorney's file pertaining to this offense for which I am charged to Four County Mental Health Center, DCF, and the investigating Law Enforcement Agencies, or any other such person or agencies for us in determing whether I am a suitable candidate for diversion. I further authorize any person, agency, or organization to release and provide, upon request, any information to the office of the District Attorney in consideration of any application for Diversion. I further authorize any person, agency, or organization that is conduction an evaluation or treatment as part of the diversion application for the diversion agreement to release information to any other person, agency, or organization as needed for the evaluation or treatment process.