APPLICATION MAILING ADDRESS STREET OR P.O. BOX CITY STATE ZIPCODE HOW WOULD YOU PREFER TO RECEIVE CORRESPONDENCE? BY MAIL OR BY ADDRESS

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1 APPLICATION FULL NAME (LAST) (FIRST) (MIDDLE) (JR, III, etc.) MAILING ADDRESS STREET OR P.O. BOX CITY STATE ZIPCODE HOW WOULD YOU PREFER TO RECEIVE CORRESPONDENCE? BY MAIL OR BY ADDRESS SOCIAL SECURITY NUMBER RACE SEX HOME PHONE (Include Area Code) CELL PHONE MAIDEN NAME ALIAS/NICKNAME AGE BIRTH DATE STATE OF BIRTH FOR STATISTICAL PURPOSES ONLY: Circle Answers that apply to you. MARITAL STATUS EDUCATION EMPLOYMENT STATUS PERSONAL INCOME HOUSEHOLD INCOME MARRIED FULL-TIME STUDENT EMPLOYED FULL-TIME $0 TO $5, $0 TO $5, WIDOWED PART-TIME STUDENT EMPLOYED PART-TIME $5,000 TO $10,000 $5,000 TO $10,000 DIVORCED NOT APPLICABLE UNEMPLOYED $10,000 TO $20,000 $10,000 TO $20,000 SEPARATED COMPLETED GED DISABLED $20,000 TO $30,000 $20,000 TO $30,000 NEVER MARRIED YEARS COMPLETED RETIRED $30,000 TO $40,000 $30,000 TO $40,000 COHABITATION DSS $40,000 TO $50,000 $40,000 TO $50,000 MILITARY VETERAN $50,000 PLUS $50,000 PLUS WHERE EMPLOYED? HOW LONG? WORK PHONE? LIST TWO (2) PERSONS WITH WHOM YOU ARE ALLOWING PTI TO DISCUSS YOUR CASE: SPOUSE / PARENTS / FRIENDS NAME ADDRESS PHONE RELATIONSHIP NAME ADDRESS PHONE RELATIONSHIP HAVE YOU EVER PARTICIPATED IN PTI IN SOUTH CAROLINA? YES NO WHERE? DO YOU WANT THIS CASE TRANSFERRED TO ANOTHER COUNTY IN SC? YES NO WHERE:

2 WHAT ARE YOU CHARGED WITH? WERE YOU TAKEN TO JAIL? YES NO WHERE? DID YOU PAY A CASH BOND/FINE? YES NO WHERE? AMOUNT? BONDSMAN ATTORNEY WAS ANYONE ELSE ARRESTED WITH YOU? YES NO (Check Status of charges below.) NAME CONVICTION? DISMISSAL? PENDING? PTI? NAME CONVICTION? DISMISSAL? PENDING? PTI? NAME THE VICTIM(S) PERSON-BUSINESS EXPLAIN THE DAMAGE, INJURY OR LOSS OF THE VICTIM FINANCIAL AMOUNT OF LOSS $ LIST ALL ARRESTS, CHARGES, INDICTMENTS, OR OTHER TROUBLE WITH THE LAW AS A JUVENILE OR AS AN ADULT OTHER THAN THIS OFFENSE. WHAT IS THE STATUS OF EACH CHARGE: CONVICTION, DISMISSAL OR PENDING? PLEASE LIST BELOW. CHARGE: DATE Probation Fine Jail Time Dismissed Pending CHARGE: DATE Probation Fine Jail Time Dismissed Pending CHARGE: DATE Probation Fine Jail Time Dismissed Pending STATEMENT OF ACCURACY: I DO HEREBY CERTIFY THAT ALL INFORMATION GIVEN ON THIS DOCUMENT IS TRUE AND ACCURATE: I HAVE NO PREVIOUS ARRESTS, CONVICTIONS, OR PENDING CHARGES THAT I HAVE NOT REVEALED IN FULL. I UNDERSTAND PTI WILL CONDUCT A COMPLETE CRIMINAL HISTORY INVESTIGATION AND THAT ANY FALSE OR UNDISCLOSED INFORMATION MAY BE GROUNDS FOR REJECTION OF TERMINATION FROM THE PROGRAM. SIGNATURE: DATE:

3 PTI PARTICIPATION CONTRACT Defendant s Name Case Number Assigned by PTI REQUIRED INFORMATION I certify that I am a qualified applicant for the Pretrial Intervention Program (PTI), and that my application for admission contains true and accurate information. I understand that any false, misleading, or erroneous information provided in my application or given during my participation in the PTI Program will constitute grounds for rejection/termination from PTI, and that upon such rejection/termination the case will be returned for prosecution. I understand that information I am required to provide may include, but will not be limited to: criminal record, education record and work record, family history, medical and/or psychiatric records and psychological testing, if any. I hereby authorize the Director of the Pretrial Intervention Program or representatives to obtain and/or release such information for any purpose directly related to my participation in the Pretrial Intervention Program. FEES I understand that I must pay a fee of $ ($ Application and $ Participation). The Application fee is non-refundable once I complete the application form. The Participation fee is non-refundable upon acceptance into PTI. Fees are accepted by money order or cashier s check only. Checks sent to you for reimbursement will be valid for 90 days. After 90 days it is your responsibility to pay the stop payment fee charged by the bank. Once the fee is paid the check will be reissued. PARTICIPATION I agree to attend and complete any and all classes, sessions, tours, programs, assignments, and any additional requirements as directed by the Pretrial Intervention staff. I understand that PTI will require me to obtain employment or to enroll in school. Extra community service hours will be required for missed deadlines. This will not include the original 60 hours required. I agree to participate in any counseling programs deemed necessary by the Pretrial Intervention staff, either individually or in group sessions, and understand that I may be directed to attend counseling sessions offered by agencies outside the Pretrial Intervention Program. I voluntarily agree to pay any fees that these outside agencies may require as a condition of my participation. I understand that no concealed weapons (knives, guns, etc.) will be allowed in the office of the Solicitor s Intervention Programs. I further understand that failure to follow the required dress code, attend classes, to keep appointments, or to complete all requirements are grounds for termination from the Pretrial Intervention Program. RESTITUTION I understand that I will be required to make full restitution to the victim(s) of the offense(s), and the amount of such restitution will be determined by the Solicitor s Office. I understand that I will be required to enter into a written contractual agreement with the victim, setting forth the amount of restitution to be paid. I further understand that failure to make full restitution according to the terms and conditions of the contract will be grounds for termination from the Pretrial Intervention Program, and that the case will be returned for prosecution, even if I have completed all other portions of the program. In the event I am terminated from the Pretrial Intervention Program prior to making full restitution to the victim, I understand that all monies I have paid as restitution belong solely and exclusively to said victim and will not be returned. I hereby waive any and all rights to such monies, and waive any and all claims to the return of any monies paid as restitution. I further release the Pretrial Intervention Program, its staff, those persons named in my contractual agreement, and their heirs, successors, executors, administrators, and assigns, from any and all claims of any kind of nature whatsoever, either in law or equity, as they may relate to monies paid as restitution. TERMINATION FROM PROGRAM I understand that should I fail to abide by the rules and regulations of the PTI Program, if completion of community service hours has been falsified or forged, or if I defraud or attempt to defraud my drug test, or in the event I am rearrested or charged with another crime, I may be terminated from the Program and that once terminated I cannot be readmitted into the PTI Program. I further understand and agree that the Solicitor s Office has sole authority to determine whether or not the rules and regulations of the Pretrial Intervention Program have been violated, and the decision to order termination from the Pretrial Intervention Program rests exclusively with the Solicitor or his designee. I further understand that if I am terminated from PTI and returned for prosecution, I will report to all terms of the court thereafter. I understand that it will be my responsibility to find out the dates and times of such court sessions.

4 COMPLETION OF PROGRAM I understand that upon successful completion that the courts will be notified to have my charge(s) dismissed. Should I choose to have the dismissal expunged I must pay to the Horry County Solicitor s office $285.00, two hundred fifty dollars ($250.00) administrative fee and thirty five dollars ($35.00) certification fee. This fee must be paid per charge unless the charges arose from the same incident. I further understand that this expungement will not apply to records of the Pretrial Intervention Programs, Solicitor s Office, State Coordinator s Office, or of the Pretrial Intervention Special Section of the South Carolina Law Enforcement Division. In addition, the Solicitor s office is not responsible for any internet companies or third party companies that have obtained my criminal information. WAIVERS AND AGREEMENTS I understand that before I can be accepted into the Pretrial Intervention Program I must, by law, give up certain statutory and constitutional rights I have pertaining to my present criminal charge(s). I hereby voluntarily agree and consent to give up the following statutory and constitutional rights upon my acceptance into the Pretrial Intervention Program. 1. I waive my right to a speedy trial. 2. I agree to the tolling of all periods of limitation established either by statutes or rules of court, including those periods of limitation applicable to any and all motions that may be pending before the Court. 3. I expressly agree to accept and abide by all the terms and conditions of the Pretrial Intervention Programs as established by the Solicitor. 4. I agree and promise to pay any and all sums established by the Solicitor as restitution for the victim(s) of the crime(s), as set forth in the signed Restitution Contract. 5. I understand and agree that any records pertaining to participation in pretrial of information obtained through Pretrial Intervention is not admissible as evidence in subsequent proceedings, criminal or civil, and communication between Pretrial Intervention Counselors and defendants shall remain as privileged communications unless a court of competent jurisdiction determines that there is compelling public interest that such communication be revealed. 6. In no case shall a written admission of guilt be required of a defendant prior to acceptance nor prior to completion of the Pretrial Intervention Program, and 7. I understand and agree that specific charges may carry additional requirements as established by the Pretrial Intervention enabling statute of the Solicitor/his designee. I voluntarily consent to participate in the Pretrial Intervention Program, and I enter into this contract freely and voluntarily, without duress, this day of, 20, in the County of Horry, State of South Carolina. Defendant PTI Representative Name of attorney representing you in this matter: CONFIDENTIALITY OF PRETRIAL INTERVENTION CLIENT RECORDS The confidentiality of Pretrial Intervention client records maintained by this program is protected by State law and Federal regulations. Generally, the program may not say to a person outside the program that a client is in the program, or disclose any information identifying a client as being in the program unless: 1. the client consents in writing; 2. the disclosure is allowed by a court order; or 3. the disclosure is made to qualified personnel for research, audit, or program evaluation. Violation of the laws and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations. State and Federal laws and regulations do not protect any information about a crime committed by the client either at the program or against any person who works for the program or about any threat to commit such a crime. State and Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities. (See SC Code Ann. Statute et seq., as amended, for State laws and 42 CFR, part 2 for Federal regulations.)

5 ALL QUESTIONS MUST BE ANSWERED NAME: WHY DO YOU FEEL YOU SHOULD BE ALLOWED TO ENTER THE PTI PROGRAM? EXPLAIN HOW THE CHARGE OCCURRED: DO YOU THINK YOU SHOULD HAVE BEEN CHARGED: YES EXPLAIN WHY? NO HAVE YOU REMAINED CRIME FREE? EXPLAIN: WERE YOU DRINKING OR USING ANY DRUGS/MEDICATION AT THE TIME OF THE CHARGE: IF SO, EXPLAIN: WITHIN THE PAST TWELVE (12) MONTHS STATE USAGE: DRUG HOW OFTEN DO YOU USE? LAST TIME USED? ALCOHOL MARIJUANA COCAINE CRACK HEROIN PAIN MEDS METHADONE XANAX/VALIUM ECSTASY INHALANTS SYNTHETICS (MARIJUANA/BATH SALTS) STATE YOUR DRUG AND/OR ALCOHOL OF CHOICE:

6 DO YOU THINK YOU HAVE A PROBLEM WITH ALCOHOL/DRUGS? EXPLAIN: LIST ANY HISTORY OF PHYSICAL, PSYCHOLOGICAL, AND/OR SEXUAL ABUSE: HAVE YOU EVER BEEN IN ANY TYPE COUNSELING? EXPLAIN: ALCOHOL/DRUG / MENTAL HEALTH / ADSAP / SCIP / MARRIAGE / FAMILY VOCATIONAL REHABILITATION / PRIVATE COUNSELING DO YOU FEEL YOU NEED TO BE INVOLVED IN COUNSELING AT THIS TIME? EXPLAIN: LIST ANY MEDICAL PROBLEMS: (INCLUDE ANY MEDICATIONS): DESCRIBE YOUR RELATIONSHIP WITH YOUR SPOUSE, GIRLFRIEND OR BOYFRIEND: DESCRIBE YOUR RELATIONSHIP WITH YOUR PARENTS: WHAT CHANGES HAVE YOU MADE SINCE YOUR CHARGE: