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53. Do you have any court dates pending? _Yes — No <br />54. If yes: County: <br />55. Date/s: <br />56. Do you expect to serve any jail sentence / workhouse time? Yes No <br />57. If yes: County: <br />58. Start Date: <br />59. Do you have any warrants? _Yes No <br />50. County: <br />!f yes, please be aware that any active warrants will be served at the time of your appointment. <br />Chemical Usage information <br />61. Do you currently use Heroin, Opiates or any IV drugs? Yes _ No <br />62. Date of Cast IV use? <br />63. Other <br />DECLARATIONS <br />Why the County needs this information: The information that you give us will be used to decide what kind of help <br />you need and if we can pay for it. Unless the law says we can or unless you tell us we call, we will not give anyone <br />else any information about you. You have the right to see any information that we have about you. If you do not <br />tell us the information that we need to know, we may not help you. <br />Rule 25 Applicant: By my signature below I attest that the information provided in this application is true and <br />correct. I know that I may have to pay a fee based upon my income. I agree to pay the fee, if any. I acknowledge <br />that I may have to pay the full cost of these services if 1 do not tell the truth in this application. <br />I also understand that until ►ALL verifications requested in this application are provided <br />that my application cannot be processed. <br />(Client name - print) (Date) <br />{Client signature) <br />