2. Van Buren County Probation Office

4. Statement from the State of Michigan Department of Corrections

   Your case has been referred to the Probation Department for purposes of conducting a Pre-Sentence Investigation for the Court. Your cooperation is necessary as all the information provided to our department must be verified for accuracy.

   Please call (269) 657-8214 Monday - Friday between 8 AM and 5 PM to make an appointment with a pre-sentence investigator. You MUST call to set up your appointment within 24 hours of taking your plea.

   Please immediately fill out your pre-sentence questionnaire. You will be given instructions on how to return the questionnaire by the pre-sentence investigator.

   Failure to provide necessary information or failure to keep an appointment may result in the cancellation of your bond and may affect the outcome of your sentencing. You are expected to comply with the scheduling of your interview either electronically or in person. If a problem should arise, you must notify the Probation Department immediately.

   Please be prepared for your interview by collecting and providing any/all available documents listed below to the agent at the time of your interview.

   1. Driver's license, state identification or other valid picture identification
   2. Birth certificate
   3. Social Security card
   4. Pay stub or letter from your employer on letterhead
   5. Proof of monthly state assistance information (ADC, SSI, Etc.)
   6. Diploma or GED and/or current report card if enrolled in school
   7. Certificates or degrees earned from vocational school, trade school, or college
   8. Letters verifying dates of substance abuse/mental health counseling
   9. AA/NA attendance sheets
   10. Proof of military service
6. Please fill out this form completely. Your submitted form will be sent to the Van Buren County Probation Office.

   The following information will be used in the Pre-Sentence Report. It is confidential. You must answer it accurately and completely, do not skip any sections or it may lengthen your interview time. If you do not know part of the information requested, fill in what you do know and you can bring the additional information with you at the time of the interview.

8. Name
10. Previous names including maiden, street, gang, nicknames or aliases:
12. Birth Date:
13. Birth City:
14. Birth State:
16. Birth country:
17. US Citizen:

    1. Yes
    2. No
18. Social Security #:
20. Drivers license or state ID #:
21. Is your license valid?

    1. Yes
    2. No
23. Residential address:
25. City:
26. State:
27. Zip:
29. Whom Do You Live With?
31. Date you moved in:
32. Do You Receive Mail Here?

    1. Yes

    1. No
34. If not, provide your mailing address.
36. Mailing address:
38. City:
39. State:
40. Zip:
42. Home phone:
43. Cell phone:
45. Message phone:
46. Name of phone owner:
48. Email address:
52. PERSONAL INFORMATION
54. Eye color:
55. Hair color:
56. Race:
58. Religion:
59. Marital status:
60. # of dependents:
62. Which are you:

    1. Right-handed
    2. Left-handed
63. Weight:
64. Height:
65. Do you wear:

    1. Glasses
    2. Contacts
69. ID MARKS
71. List any identifying scars, marks, tattoos, or amputations.
73. Mark:
74. Body part:
76. Description:
80. Mark:
81. Body part:
83. Description:
87. Mark:
88. Body part:
90. Description:
94. Mark:
95. Body part:
97. Description:
101. Mark:
102. Body part:
104. Description:
108. Mark:
109. Body part:
111. Description:
115. Mark:
116. Body part:
118. Description:
122. Mark:
123. Body part:
125. Description:
129. Mark:
130. Body part:
132. Description:
136. Mark:
137. Body part:
139. Description:
143. Mark:
144. Body part:
146. Description:
150. CURRENT OR PREVIOUS PROBATION OR PAROLE
152. Have you been on probation or parole in the past?

     1. Yes

     1. No
153. If yes, where?
155. Explain:
157. Name of agent(s):
159. What was your age at first arrest?
160. Other criminal charges pending?

     1. Yes

     1. No
162. If yes, what are the charges and where?
164. If you have lived in any other states since the age of 16, list each state and city:
168. YOUR FAMILY
170. Father:
172. Name:
173. Birth date:
174. Age:
176. Address:
178. City:
179. State:
180. Zip:
182. Telephone:
183. Cell phone:
185. Place of employment:
186. Type of job:
188. If deceased, when and cause:
190. Past trouble/probation/parole:
194. Mother:
196. Name:
197. Birth date:
198. Age:
200. Maiden/previous name(s):
202. Address:
204. City:
205. State:
206. Zip:
208. Telephone:
209. Cell phone:
211. Place of employment:
212. Type of job:
214. If deceased, when and cause:
216. Past trouble/probation/parole:
220. Was either parent married before?

     1. Yes

     1. No
221. Which one?
223. To whom and when?
227. If your parents are divorced, list the name of your step-father or step-mother.
229. Step-father:
231. Name:
232. Birth date:
233. Age:
235. Address:
237. City:
238. State:
239. Zip:
241. Telephone:
242. Cell phone:
244. Place of employment:
245. Type of job:
247. If deceased, when and cause:
249. Past trouble/probation/parole:
253. Step-mother:
255. Name:
256. Birth date:
257. Age:
259. Address:
261. City:
262. State:
263. Zip:
265. Telephone:
266. Cell phone:
268. Place of employment:
269. Type of job:
271. If deceased, when and cause:
273. Past trouble/probation/parole:
277. List brothers and sisters or other significant family members:
279. Name:
280. Birth date:
281. Relationship:
283. Address:
285. City:
286. State:
287. Zip:
289. Telephone:
290. Cell phone:
292. Place of employment:
293. Type of job:
295. Past trouble/probation/parole:
299. Name:
300. Birth date:
301. Relationship:
303. Address:
305. City:
306. State:
307. Zip:
309. Telephone:
310. Cell phone:
312. Place of employment:
313. Type of job:
315. Past trouble/probation/parole:
319. Name:
320. Birth date:
321. Relationship:
323. Address:
325. City:
326. State:
327. Zip:
329. Telephone:
330. Cell phone:
332. Place of employment:
333. Type of job:
335. Past trouble/probation/parole:
339. Name:
340. Birth date:
341. Relationship:
343. Address:
345. City:
346. State:
347. Zip:
349. Telephone:
350. Cell phone:
352. Place of employment:
353. Type of job:
355. Past trouble/probation/parole:
359. Name:
360. Birth date:
361. Relationship:
363. Address:
365. City:
366. State:
367. Zip:
369. Telephone:
370. Cell phone:
372. Place of employment:
373. Type of job:
375. Past trouble/probation/parole:
379. Name:
380. Birth date:
381. Relationship:
383. Address:
385. City:
386. State:
387. Zip:
389. Telephone:
390. Cell phone:
392. Place of employment:
393. Type of job:
395. Past trouble/probation/parole:
399. Name:
400. Birth date:
401. Relationship:
403. Address:
405. City:
406. State:
407. Zip:
409. Telephone:
410. Cell phone:
412. Place of employment:
413. Type of job:
415. Past trouble/probation/parole:
419. MARITAL HISTORY
421. Are you:

     1. Married
     2. Single

     1. Widowed
     2. Divorced

     1. Engaged
423. Your spouse:
425. If you are unmarried, but living with a significant other, what is his/her name?
426. Birth date:
428. Marriage:
430. Your wife or husband's name:
431. Maiden name:
433. Date of marriage:
434. City and State:
436. Age:
437. Birth date:
438. Telephone:
440. Address:
442. City:
443. State:
444. Zip:
446. Education (Highest grade completed):
447. Place of employment:
449. How old were you at the time of the wedding?
450. How old was he or she?
452. Was she or were you ever pregnant? (As the case may be)

     1. Yes

     1. No
453. Have you ever separated?

     1. Yes

     1. No
455. If divorced, date of divorce:
456. Who started the proceedings?
458. Why?
462. Previous marriage(s):
464. Your ex-wife or ex-husband's name:
465. Maiden name:
467. Date of marriage:
468. City and State:
470. Age:
471. Birth date:
472. Telephone:
474. Address:
476. City:
477. State:
478. Zip:
480. Education (Highest grade completed):
481. Place of employment:
483. How old were you at the time of the wedding?
484. How old was he or she?
486. Was she or were you ever pregnant? (As the case may be)

     1. Yes

     1. No
487. Have you ever separated?

     1. Yes

     1. No
489. If divorced, date of divorce:
490. Who started the proceedings?
492. Why?
496. Your ex-wife or ex-husband's name:
497. Maiden name:
499. Date of marriage:
500. City and State:
502. Age:
503. Birth date:
504. Telephone:
506. Address:
508. City:
509. State:
510. Zip:
512. Education (Highest grade completed):
513. Place of employment:
515. How old were you at the time of the wedding?
516. How old was he or she?
518. Was she or were you ever pregnant? (As the case may be)

     1. Yes

     1. No
519. Have you ever separated?

     1. Yes

     1. No
521. If divorced, date of divorce:
522. Who started the proceedings?
524. Why?
528. YOUR CHILDREN AND STEP-CHILDREN
530. If you are male, is anyone currently pregnant by you?

     1. Yes

     1. No
532. If so, who?
533. Due date:
535. If you are female, are you pregnant?

     1. Yes
     2. No
537. If so, who is the father?
538. Due date:
540. List sons and daughters (oldest first, also list step-children):
542. Name:
543. Birth date:
544. Child is:

     1. Son
     2. Daughter
546. Address:
548. City:
549. State:
550. Zip:
552. Telephone:
553. Cell phone:
555. Place of employment or school:
557. Education (Highest grade):
558. # of children:
559. Husband or wife:
561. Do you pay child support?

     1. Yes
     2. No
562. How much per week?
563. Are you up to date?

     1. Yes
     2. No
565. Other parent's name:
566. Birth date:
567. Age:
569. Address:
571. City:
572. State:
573. Zip:
575. Place of employment or school:
577. Education (Highest grade):
578. # of children:
579. Husband or wife:
583. Name:
584. Birth date:
585. Child is:

     1. Son
     2. Daughter
587. Address:
589. City:
590. State:
591. Zip:
593. Telephone:
594. Cell phone:
596. Place of employment or school:
598. Education (Highest grade):
599. # of children:
600. Husband or wife:
602. Do you pay child support?

     1. Yes
     2. No
603. How much per week?
604. Are you up to date?

     1. Yes
     2. No
606. Other parent's name:
607. Birth date:
608. Age:
610. Address:
612. City:
613. State:
614. Zip:
616. Place of employment or school:
618. Education (Highest grade):
619. # of children:
620. Husband or wife:
624. Name:
625. Birth date:
626. Child is:

     1. Son
     2. Daughter
628. Address:
630. City:
631. State:
632. Zip:
634. Telephone:
635. Cell phone:
637. Place of employment or school:
639. Education (Highest grade):
640. # of children:
641. Husband or wife:
643. Do you pay child support?

     1. Yes
     2. No
644. How much per week?
645. Are you up to date?

     1. Yes
     2. No
647. Other parent's name:
648. Birth date:
649. Age:
651. Address:
653. City:
654. State:
655. Zip:
657. Place of employment or school:
659. Education (Highest grade):
660. # of children:
661. Husband or wife:
665. Name:
666. Birth date:
667. Child is:

     1. Son
     2. Daughter
669. Address:
671. City:
672. State:
673. Zip:
675. Telephone:
676. Cell phone:
678. Place of employment or school:
680. Education (Highest grade):
681. # of children:
682. Husband or wife:
684. Do you pay child support?

     1. Yes
     2. No
685. How much per week?
686. Are you up to date?

     1. Yes
     2. No
688. Other parent's name:
689. Birth date:
690. Age:
692. Address:
694. City:
695. State:
696. Zip:
698. Place of employment or school:
700. Education (Highest grade):
701. # of children:
702. Husband or wife:
706. Name:
707. Birth date:
708. Child is:

     1. Son
     2. Daughter
710. Address:
712. City:
713. State:
714. Zip:
716. Telephone:
717. Cell phone:
719. Place of employment or school:
721. Education (Highest grade):
722. # of children:
723. Husband or wife:
725. Do you pay child support?

     1. Yes
     2. No
726. How much per week?
727. Are you up to date?

     1. Yes
     2. No
729. Other parent's name:
730. Birth date:
731. Age:
733. Address:
735. City:
736. State:
737. Zip:
739. Place of employment or school:
741. Education (Highest grade):
742. # of children:
743. Husband or wife:
747. Name:
748. Birth date:
749. Child is:

     1. Son
     2. Daughter
751. Address:
753. City:
754. State:
755. Zip:
757. Telephone:
758. Cell phone:
760. Place of employment or school:
762. Education (Highest grade):
763. # of children:
764. Husband or wife:
766. Do you pay child support?

     1. Yes
     2. No
767. How much per week?
768. Are you up to date?

     1. Yes
     2. No
770. Other parent's name:
771. Birth date:
772. Age:
774. Address:
776. City:
777. State:
778. Zip:
780. Place of employment or school:
782. Education (Highest grade):
783. # of children:
784. Husband or wife:
788. EMPLOYMENT
790. What is the longest period of time you have ever held one job?
791. Which job?
793. List your last five (5) jobs, beginning from present job:
795. Name of employer:
796. Telephone:
798. Address:
800. City:
801. State:
802. Zip:
804. Start date:
805. Supervisor or foreman's name:
807. End date:
808. Wage per hour:
809. Type of employment:

     1. Full-time

     1. Part-time
811. Type of job:
813. Reason for leaving:
815. What shift do/did you work?
816. Time in:
     Time in:
817. Time out:
     Time out:
821. Name of employer:
822. Telephone:
824. Address:
826. City:
827. State:
828. Zip:
830. Start date:
831. Supervisor or foreman's name:
833. End date:
834. Wage per hour:
835. Type of employment:

     1. Full-time

     1. Part-time
837. Type of job:
839. Reason for leaving:
841. What shift do/did you work?
842. Time in:
     Time in:
843. Time out:
     Time out:
847. Name of employer:
848. Telephone:
850. Address:
852. City:
853. State:
854. Zip:
856. Start date:
857. Supervisor or foreman's name:
859. End date:
860. Wage per hour:
861. Type of employment:

     1. Full-time

     1. Part-time
863. Type of job:
865. Reason for leaving:
867. What shift do/did you work?
868. Time in:
     Time in:
869. Time out:
     Time out:
873. Name of employer:
874. Telephone:
876. Address:
878. City:
879. State:
880. Zip:
882. Start date:
883. Supervisor or foreman's name:
885. End date:
886. Wage per hour:
887. Type of employment:

     1. Full-time

     1. Part-time
889. Type of job:
891. Reason for leaving:
893. What shift do/did you work?
894. Time in:
     Time in:
895. Time out:
     Time out:
899. Name of employer:
900. Telephone:
902. Address:
904. City:
905. State:
906. Zip:
908. Start date:
909. Supervisor or foreman's name:
911. End date:
912. Wage per hour:
913. Type of employment:

     1. Full-time

     1. Part-time
915. Type of job:
917. Reason for leaving:
919. What shift do/did you work?
920. Time in:
     Time in:
921. Time out:
     Time out:
925. MILITARY
927. Branch of service:
928. Entry date:
929. Discharge date:
931. Type of discharge:
933. Highest rank held:
934. Status:

     1. Active
     2. Inactive
935. Service #:
937. Disciplinary actions:
941. EDUCATION
943. School name:
945. Address:
946. Phone:
948. Dates attended (from - to):
949. Date graduated or dropped out:
951. Area of study:
952. Certificate or degree:
956. School name:
958. Address:
959. Phone:
961. Dates attended (from - to):
962. Date graduated or dropped out:
964. Area of study:
965. Certificate or degree:
969. School name:
971. Address:
972. Phone:
974. Dates attended (from - to):
975. Date graduated or dropped out:
977. Area of study:
978. Certificate or degree:
982. School name:
984. Address:
985. Phone:
987. Dates attended (from - to):
988. Date graduated or dropped out:
990. Area of study:
991. Certificate or degree:
995. List any extracurricular activities you participated in while in school:
997. Did you ever skip school?

     1. Yes

     1. No
998. How often?
1000. Were you ever suspended?

      1. Yes

      1. No
1001. When?
1003. Why?
1005. Were you ever expelled?

      1. Yes

      1. No
1006. When?
1008. Why?
1010. If you dropped out of school, explain why:
1012. What, if any, are your plans for furthering your education?
1016. SUBSTANCE ABUSE HISTORY
1018. Alcohol
1019. Age of first use:
1020. Start date:
1021. End date:
1023. Frequency:
1024. Amount used:
1028. Marijuana
1029. Age of first use:
1030. Start date:
1031. End date:
1033. Frequency:
1034. Amount used:
1038. Cocaine or Crack
1039. Age of first use:
1040. Start date:
1041. End date:
1043. Frequency:
1044. Amount used:
1048. Amphetamines, Meth or Speed
1049. Age of first use:
1050. Start date:
1051. End date:
1053. Frequency:
1054. Amount used:
1058. Barbiturates, Downers
1059. Age of first use:
1060. Start date:
1061. End date:
1063. Frequency:
1064. Amount used:
1068. Hallucinogens, LSD, PCP, Mushrooms
1069. Age of first use:
1070. Start date:
1071. End date:
1073. Frequency:
1074. Amount used:
1078. Heroin
1079. Age of first use:
1080. Start date:
1081. End date:
1083. Frequency:
1084. Amount used:
1088. Prescription Drugs
1089. Age of first use:
1090. Start date:
1091. End date:
1093. Frequency:
1094. Amount used:
1098. Other
1099. Age of first use:
1100. Start date:
1101. End date:
1103. Frequency:
1104. Amount used:
1108. Do you feel you need treatment now?

      1. Yes
      2. No
1109. Have you ever injected drugs?

      1. Yes
      2. No
1110. What is the longest length of time that you have been drug free?
1112. Which of your family members have had problems with drugs or alcohol?
1114. Have you ever received drug or alcohol treatment in the past?

      1. Yes

      1. No
1118. SUBSTANCE ABUSE TREATMENT
1120. AA/NA/Self Help
1121. Start date:
1122. End date:
1124. Provider:
1125. Completed?

      1. Yes
      2. No
1127. Notes:
1131. Assessment
1132. Start date:
1133. End date:
1135. Provider:
1136. Completed?

      1. Yes
      2. No
1138. Notes:
1142. Detoxification
1143. Start date:
1144. End date:
1146. Provider:
1147. Completed?

      1. Yes
      2. No
1149. Notes:
1153. Didactic
1154. Start date:
1155. End date:
1157. Provider:
1158. Completed?

      1. Yes
      2. No
1160. Notes:
1164. Dual Diagnosis
1165. Start date:
1166. End date:
1168. Provider:
1169. Completed?

      1. Yes
      2. No
1171. Notes:
1175. Educational
1176. Start date:
1177. End date:
1179. Provider:
1180. Completed?

      1. Yes
      2. No
1182. Notes:
1186. Intensive Outpatient
1187. Start date:
1188. End date:
1190. Provider:
1191. Completed?

      1. Yes
      2. No
1193. Notes:
1197. Methadone Detoxification
1198. Start date:
1199. End date:
1201. Provider:
1202. Completed?

      1. Yes
      2. No
1204. Notes:
1208. Outpatient
1209. Start date:
1210. End date:
1212. Provider:
1213. Completed?

      1. Yes
      2. No
1215. Notes:
1219. Residential
1220. Start date:
1221. End date:
1223. Provider:
1224. Completed?

      1. Yes
      2. No
1226. Notes:
1230. HEALTH
1232. Do you have any serious mental health problems?

      1. Yes

      1. No
1234. If so, please list:
1236. Are you receiving disability benefits or workers' compensation?

      1. Yes

      1. No
1238. Are you currently taking prescription medications?

      1. Yes

      1. No
1240. If yes, which ones and why were they prescribed?
1242. Do you have health insurance or Medicaid?

      1. Yes
      2. No
1243. If so, what is the company's name?
1245. Have you ever been seen by a psychologist or psychiatrist?

      1. Yes
      2. No
1246. When?
1247. Where?
1251. FINANCES
1253. How do you support yourself?
1255. List all income you receive, including partners or parents (from whom & how much):
1257. Are you receiving public assistance? (ADC, etc.)

      1. Yes
      2. No
1258. Do you receive unemployment benefits?

      1. Yes
      2. No
1260. If so, what type?
1262. How much per month?
1263. Why?
1265. Caseworker's name:
1266. Case #:
1268. Do you have any savings?

      1. Yes
      2. No
1269. How much?
1270. Where?
1272. Do you own your own home?

      1. Yes
      2. No
1273. Are you:

      1. Buying
      2. Renting
1274. Rent or house payment monthly amount:
1276. Do you live with your parents?

      1. Yes
      2. No
1277. Do you pay room & board?

      1. Yes
      2. No
1278. How much?
1279. Per:

      1. Week
      2. Bi-weekly
      3. Month
1281. Do you have a car/truck?

      1. Yes
      2. No
1282. If so, give the year, model, make and color:
1284. License plate #:
1285. If you are buying the vehicle, what is the monthly payment amount?
1287. If you do not have a vehicle, describe the vehicle that you drive:
1289. License plate #:
1290. Who owns the vehicle?
1292. Do you won any other motor vehicles, boats, motorcycles, RVs, etc.?

      1. Yes

      1. No
1294. If so, list here:
1296. Do you have anything valued over $1500.00?
1298. List all debts, including credit cards:
1302. CRIMINAL JUSTICE HISTORY
1304. Date of arrest:
1305. Police Department:
1306. Did you have an Attorney?

      1. Yes
      2. No
1308. Offense:
1310. Sentence:
1314. Date of arrest:
1315. Police Department:
1316. Did you have an Attorney?

      1. Yes
      2. No
1318. Offense:
1320. Sentence:
1324. Date of arrest:
1325. Police Department:
1326. Did you have an Attorney?

      1. Yes
      2. No
1328. Offense:
1330. Sentence:
1334. Date of arrest:
1335. Police Department:
1336. Did you have an Attorney?

      1. Yes
      2. No
1338. Offense:
1340. Sentence:
1344. Date of arrest:
1345. Police Department:
1346. Did you have an Attorney?

      1. Yes
      2. No
1348. Offense:
1350. Sentence:
1354. Date of arrest:
1355. Police Department:
1356. Did you have an Attorney?

      1. Yes
      2. No
1358. Offense:
1360. Sentence:
1364. Date of arrest:
1365. Police Department:
1366. Did you have an Attorney?

      1. Yes
      2. No
1368. Offense:
1370. Sentence:
1374. Date of arrest:
1375. Police Department:
1376. Did you have an Attorney?

      1. Yes
      2. No
1378. Offense:
1380. Sentence:
1384. GANG INVOVLEMENT
1386. Did you ever or do you currently belong to a gang?

      1. Yes
      2. No
1387. Gang name:
1389. Gang rank or position/level:
1393. CURRENT OFFENSE
1395. Present offense:
1397. Name of your Attorney:
1398. Appointed or Retained?

      1. Appointed
      2. Retained
1400. Please describe the present offense in your own words. What did you do? What happened?
1402. Why did you get involved?
1404. Include any other information that the Judge should know or consider:
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1406. 1. Receive an email copy of this form.
1407. Email address

      This field is not part of the form submission.

1408. Submit

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