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2. Case Number
4. Name (First, Last)*
6. Address
8. City, State, ZIP Code
10. Email Address
12. Phone Number
14. I have submitted documentation for the following:

    1. Completion of Counseling
    2. Completed Community Service or Donation to Cochise County Non-Profit
    3. Completion of On-Line or In-Person Class
    4. Paid Restitution
    5. Other
16. Please Specify
18. Note:

    Additional documentation can be submitted in the area below or emailed to diversion@cochise.az.gov.

20. Upload Documentation
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22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

* indicates a required field