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Offender’s Fund

The Offender’s Fund in the 14th Judicial District is a limited resource designed to assist certain people with the initial financial costs of starting rehabilitative treatment programs, such as substance abuse intervention or mental health and emotional counseling. It is not designed to pay for all treatment, but rather to serve as a subsidy for the first phase of recovery. It is for applicants who are sincere in their efforts to comply with the terms of their probation and make positive changes in their lives from day one of their sentence.

Personal Information
Name:*
First Last
County:*
Case Number:*
Physical address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Alternate mailing address?*
- Yes
- No
Mailing address:*
Street Address Address Line 2 City State ZIP Code
Phone:*
Work phone:
Email:*
Date of Birth:*
MM slash DD slash YYYY
Marital Status:*
- Single
- Married
- Divorced
Sex:*
- Male
- Female
Date of offense on which you are charged:*
MM slash DD slash YYYY
Describe charge(s) against you:*
Are you presently on supervised probation?*
- Yes
- No
Who is your probation officer?*
Funding Request
Describe the funding you are seeking and what purpose it will be used for:*
Counseling?*
- Yes
- No
Frequency (not to exceed 6 months):*
- Weekly
- Monthly
Number of sessions per period:*
i.e. two per week, four per month etc.
Drug testing?*
- Yes
- No
Frequency (not to exceed 6 months):*
- Weekly
- Monthly
Number of sessions per period:*
i.e. two per week, four per month etc.
Total cost $*
Portion you can pay $*
Amount requested $*
What agency will this money be paid to:*
From what other sources have you tried to obtain the funding:*
Are you willing to repay some or all of a grant if awarded?*
- Yes
- No
Please indicate how much you could repay and propose a repayment schedule:*
Do you have any insurance which you believe would aid you in your request?*
- Yes
- No
How timely would you receive any help from your insurance company?*
If you received insurance money, would you repay the fund with that money?*
Financial Statement
The following is a complete and accurate disclosure of my estate as required by C.R.S. 16-11-102 or C.R.S. 19-2-206.6
ASSETS
Cash on hand $*
Location:*
Checking account balance $*
Bank and account number:*
If you have a savings account, balance $
Bank and account number:
Do you own a vehicle?*
- Yes
- No
Make and model:*
Vehicle value $*
Amount owed:*
Second vehicle make and model:
Vehicle value $
Amount owed:
Do you own a home?*
- Yes
- No
Current value $*
Amount owed $*
Other real estate?*
- Yes
- No
Current value $*
Amount owed $*
Stocks/bonds/funds?*
Other assets?*
i.e. art, jewelry etc.
Other assets?*
i.e. tax refunds, time shares etc.
TOTAL ASSETS $*
INCOME
Monthly income $*
i.e. wages, tips, and bonuses
Employer:*
Hours worked per week?*
Additional earnings $
i.e. earnings from spouse or parents
Employer:
Hours worked per week?
Do you have retirement income?*
- Yes
- No
(excluding SSI)
Retirement amount $*
Source:*
Do you have Investment income?*
- Yes
- No
Amount?*
Source:*
Other income and source?
TOTAL MONTHLY INCOME $*
MONTHLY EXPENSES
Rent/Mortgage $*
Associations fees $*
Phone bill $*
Food/Clothing $*
Utilities $*
i.e. water, propane, gas, electric, etc.
Do you pay child support?*
- Yes
- No
Amount $*
Number of children:*
Number that live with you?*
Do you pay alimony?
- Yes
- No
Amount $*
Do you have medical bills?*
- Yes
- No
Installment payment $*
Describe:*
List any other expenses and amounts:
TOTAL MONTHLY EXPENSES $*
Signature*
I, the applicant, hereby state UNDER PENALTIES OF PERJURY AND FALSIFICATION that this electronic submission has been prepared by me and that the information given herin is true and accurate to the best of my knowledge, including the financial information above.
Consent*
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