Permanent Address: STUDENT LEGAL SERVICE AO CASE INTAKE

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STUDENT LEGAL SERVICE
AO CASE INTAKE THIS BOX FOR OFFICE USE
ONLY
CITY ORDINANCE VIOAppt
LATION/CITY OFFENSE Date: ________ Time: _______
http://www.odos.uiuc.edu/sls
NOTE: This form is to be used for City Ordinance Violation or "City Offense"
SYH
JDG
tickets, such as drinking tickets, noise violations, etc. To address Traffic ATTY: TEB
tickets or an accident, or Misdemeanor charges, issues with your housing
lease or landlord, OR would like to request Power of Attorney documents, Type: ____________________
or have an issue not listed here, please select the correct forms for
those issues on the website.
Students who are assessed and pay the S.O.R.F. fee are eligible to consult Student Legal Services during the
semester that the fee is assessed, until the first day of the next term, including summer.
Once the form is completed, you must print it and bring it into the Student Legal Service Office, during regular
office hours (8:30am-Noon, 1:00-4:30pm) at 324 Illini Union and present it with your I-card. You will then be
set up with an appointment to discuss your issues with an attorney. This form may be destroyed in five (5) years.
Family Name
What is your year/class at UIUC?
First Name
Freshman
Sophomore
Junior
Senior
Graduate
Law/Med/Vet
Middle
Have you used Student Legal Service
previously?
Yes
No
If not, how did you learn
about Student Legal
Service (select one)?
LOCAL ADDRESS:
Dormitory (select)
Room #
OR
Street Address:
Be sure to include
apartment # & city
May we contact you by email?
Yes
No
Zip Code
Other zip code:
Local Landline phone #
Other email:
Cell Phone #
What is your College at UIUC?
UIUC Office phone #
Major?
Permanent Address:
Street address,
City, State, Zip Code
REQUIRED: Are you a U.S. Citizen?
Permanent Phone Number:
Yes
No
@uiuc.edu
Ticket(s) issued for what offense(s)?
****Be sure to bring your ticket in to the office with this form! ****
Why was student stopped initially?
Circumstances of offense
(what happened)
Any witnesses? (Name,
address, phone #, if known)
Did you admit guilt to officer?
Yes
No Explain:
What date is ticket due
if paid by mail?
What is the amount due? $
Previous City Offense ticket(s)?
Ticket for what offense?
Date?
Conviction? (if you
paid the ticket, yes.)
Yes
No
Ticket for what offense?
Date?
Conviction? (if you
paid the ticket, yes.)
Yes
No
Do you have a CRIMINAL record?
Have you every been on Court Supervision
before?, including for traffic offenses?
If yes, where, when, and for what offense?
Are you aware that a "City Offense" or "Ordinance Violation" is only a civil fine if paid
by mail and will not count as a criminal record if paid by mail before the due date?
Yes
No
I am a student currently enrolled for the current semester in credit-bearing courses of at least six hours, or
equivalent, at the University of Illinois at Urbana-Champaign
I have been assessed the S.O.R.F. fee of FOURTEEN DOLLARS ($14.00) and have not sought a refund of the SORF fee
at the University for the current semester. If I obtain a refund of anySORF fee while I am consulting with or being
represented by an attorney at Student Legal Service, I understand that I can no longer be represented.
I acknowledge being advised through this form and specifically agree that the Attorneys at Student Legal Service
act independently of the University of Illinois; the Attorneys are neither a part of nor agents of the University of
Illinois.
I understand that this form may be destroyed in five (5) years.
Date:
Signature:
Please sign form AFTER printing.
This form may be destroyed in 5 (five) years.
Print Form
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