El Dorado — Application for Admission Into Veterans Treatment Court

Source: https://www.eldorado.courts.ca.gov/system/files/forms-and-filings/cr-183-application-admission-veterans-treatment-court_072225.pdf

ATTORNEY OR PARTY WITHOUT ATTORNEY STATE BAR NUMBER: FOR COURT USE ONLY NAME: FIRM NAME: STREET ADDRESS: CITY: STATE: ZIP CODE: TELEPHONE NO: FAX NO: EMAIL ADDRESS: ATTORNEY FOR: SUPERIOR COURT OF CALIFORNIA, COUNTY OF EL DORADO ☐ 495 Main Street, Placerville, CA 95667 ☐ 1354 Johnson Blvd., South Lake Tahoe, CA 96150

PEOPLE OF THE STATE OF CALIFORNIA v. CASE NUMBER

Defendant:

APPLICATION FOR ADMISSION INTO VETERANS TREATMENT COURT

☐Post Plea Veterans Treatment Court (PC 1170.9) ☐ Military Diversion (PC 1001.80)

1. I, , am an Active Duty Member, or a Veteran of the United States Armed Services.
2. I understand that: a. To be considered for Veterans Treatment Court (VTC), signed copies of this Application, the Veterans Referral Form for Northern CA VA Healthcare, and the Request for and Authorization to Release Health Information forms must be delivered electronically to: Northern CA VA Healthcare Attention: Sherry DeLisle sherry.delisle@va.gov b. VTC involves a long-term treatment program (12-24 months) with required terms and conditions and may also include probation terms. c. If admitted, I will be subject to VTC terms and conditions, which may include electronic monitoring, alcohol and/or drug testing, and for violations, sanctions may be imposed, including but not limited to flash incarcerations. Additional terms and conditions may apply. d. Any restitution that I owe to any victim of a crime I have committed will remain due and payable until paid, even if I complete VTC.
3. My information: Full Name: Phone Number: Address: City: State: Zip Code:
4. I am represented by (name, address, and phone number of your attorney, if you have one): Attorney’s Name: Phone Number: Address: City: State: Zip Code:
5. I have been charged with or convicted of the following charges (or have admitted the following Probation Violations) in El

Dorado County Superior Court case number indicated above:

6. I am asking to be admitted into VTC because: (if more space is needed, attach additional page):

   ☐ Additional Page Attached

I, , understand all of the above, and acknowledge that everything I have said about myself in the preceding answers is true.

SIGN

Date Applicant’s Signature Mandatory Use Application for Admission into Veterans Page 1 of 1 Local Form CR-183 Treatment Court Effective 07/22/2025