Presentence Investigation Report Form - Nevada - Edit, Fill, Sign Online

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State of Nevada

DEPARTMENT OF PUBLIC SAFETY

Division of Parole and Probation

PRESENTENCE INVESTIGATION REPORT QUESTIONNAIRE

Name:

Criminal Case #:

Sentence Date:

Time:

Phone Number:

A Presentence Investigation has been ordered by the Court. Please complete this questionnaire accurately

and completely. Deliberate falsehoods or misrepresentation will be reported to the Court.

________If you have plead guilty to a Gross Misdemeanor or Category E felony offense, an interview is not

required. If this applies to you, submit the completed questionnaire to the Division of Parole and Probation at

____________________________(address) or submit to a jail deputy or your Correctional Caseworker no more

than 3 days from the date you entered your plea in Court.

_________If you have plead guilty to any other offense, an interview is required. Please call the phone number

provided above within three days, and ask to speak with the assigned Presentence Investigator to schedule an

interview. If you are in custody in a jail facility, an interview will be conducted at the jail. If you are in prison, the

investigator will attempt to conduct a phone interview. If you are released from custody before you are

interviewed, contact the above provided phone number immediately.

At the time of your interview, please bring the following documents:

Driver’s License/ID Card Educational Degrees

Proof of Residence Most recent paycheck stub

Alien Registration Card Proof of Mental Health/Substance abuse program attendance

Armed Forces Papers (DD214)

Be prepared to pay the following fees to the Clerk of Court on the date of sentencing:

$25 Court and $3 DNA Administrative Assessment Fee (all cases)

$35 Domestic Battery or $60 Chemical Analysis Fee, if applicable

$150 Genetic Marker Testing Fee (if your offense mandates DNA testing)



IF YOU ARE GRANTED PROBATION

You will be required to pay $30 per month in supervision fees, for the term of your probation.

The first two months ($60) MUST be paid within the first 30 days of your probation grant.

Fees MUST be paid by money order or check -NO CASH ACCEPTED.

Make payable to: “The Division of Parole and Probation”(Name & SS# must be printed clearly on the

money order or check).

IF YOU INTEND TO RESIDE IN A STATE OTHER THAN NEVADA

The first two (2) months fees ($60.00) MUST BE PAID IN ADVANCE, before you leave.

Once you have been formally acceptedfor supervision in the receiving state, you will no longer be

required to pay Nevada supervision fees. However, you may be required to pay supervision fees to the

receiving state in an amount determined by that state.

No one will be allowed to leave Nevada untilthey have reporting instructions or are accepted by the

receiving state. It may take two (2) business days or more to receive reporting instructions. If reporting

instructions are denied, you must remain in Nevada until you are accepted for supervision by the

receiving state. This process may take fifty (50) or more days, so plan accordingly.

IMPORTANT: Children are not allowed inside any Parole and Probation office.

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I. Personal Information:

Name: _____________________________________

Physical address: ______________________________________________________________________

Number Street City State Zip

Mailing Address:_______________________________________________________________________

Number Street CityState Zip

Years and months you have lived at current residence:

Are you a resident of Nevada (ie: you have a NV Driver’s License/ID Card) _______________________

Are you now or have you ever been homeless: No ( ) Yes ( )

Social Security Number: ______/____/______Place of birth: _________________________

Date of birth: _______________________ Age: _______

Phone Number: ( ) _______________________ (Home)

( ) _______________________ (Work)

( ) _______________________ (Cell)

Driver’s License/State ID#: ___________________________ What State? _______________________

Is your License valid: No ( ) Yes ( ) If no is it currently Revoked ( ) Suspended ( ) Withdrawn ( )

E-mail Address: __________________________________________

Aliases: (Maiden name)

____________________________________________________________(Prior married names)

___(Other)

U. S. citizen: _______ Citizen of what country: ___________________________________

Alien Registration Number: ______________________ Temporary ( ) Permanent ( )

What is your primary language: ___________________ Other languages spoken: ___________________

Sex____________ Race: ________

Height: _________ Weight: _________ Hair color: ____________ Eye color: ___________

Scars / Marks:(List where and describe)____________________________________________________

_____________________________________________________________________________________

Tattoos: (List where and describe)_________________________________________________________

_____________________________________________________________________________________

Attorney’s name: ____________________ Retained ( ) Appointed ( ) Public Defender ( )

TO BE FILLED IN BY PNP SPECIALIST

BIN:

Criminal Case Number:

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II. Family:

a) Briefly describe your childhood.For example: Did your mother and father live together?Did

you have regular contact with other extended familymembers, such as grandparents, cousins, aunts and

uncles? Were you abused or neglected?Was there anydrug or alcohol abuse present?Was either parent

ever incarcerated?Was Social Services involved in your family?Include anyinformation you think

explains whyyou developed into the person you are: __________________________________________

_____________________________________________________________________________________

b) List immediate family members and relationship (ie: Mother, sister, brother)

Name of Family Member

And Relationship AddressPhone #

Name:

Relationship:

Name:

Relationship:

Name:

Relationship:

Name:

Relationship:

Name:

Relationship:

c. Spouse(s) and Partner(s)

Name of current spouse or partner: Legally married? ________

Do you live together?: How may months/years have you been together?

Former spouse/partners How many months/

Name and Relationship Address and phone # if known years were you together?

Name:

Relationship:

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Former spouse/partners(cont.) How many months/

Name and Relationship Address and phone # if known years were you together?

Name:

Relationship:

Name:

Relationship:

d. Children

Name and DOB Sex Age Address Who has legal custody?

Name:

DOB:

□ this is my stepchild

Name:

DOB:

□ this is my stepchild

Name:

DOB:

□ this is my stepchild

Name:

DOB:

□ this is my stepchild

Name:

DOB:

□ this is my stepchild

Name:

DOB:

□ this is my stepchild

Ifyou have been court ordered to pay child support for any of your children what is the monthly amount?

$________________Are your wages being garnished for child support: No ( ) Yes ( )

Do you owe any back child support? If yes explain ___________________________________________

Where did you grow up: _________________________________________________________________

Are any of your dependants or their guardians receiving welfare benefits?No ( ) Yes ( )

If Yes where? _________________________________________________________________________

Who, besidesyour spouse/partnerand children previously listed are living in your home now:

Name: ___________________________ Date of birth: ____________ SS #: _______________________

Are there any weapons in your home: No ( ) Yes ( )

If Yes explain (type, location, ownership):___________________________________________________

_____________________________________________________________________________________

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Whom do you keep in contact with (other than family):

Name: ____________________ Address: ___________________________________________________

Phone: __________________ How long known: _____________________________________________

IIIa. Employment

Are you currently: Employed ( ) If employed how long:

Disabled ( ) Retired ( ) Homemaker ( )

Unemployed ( ) If unemployed how long: ________________

Current employer: ____________________________Supervisor: ______________________________

Address: ______________________________________ Phone #: _______________________________

Job title: ________________________ Hours per week: _______________________________________

Salary: ________ Per month Date hired: ___________ Date terminated: ________________________

Reason for leaving: _____________________________________________________________________

Former Employers

Employer: ____________________________Supervisor: ________________________________

Address: ______________________________________ Phone #: _______________________________

Job title: ________________________ Hours per week: _______________________________________

Salary: ________ Per month Date hired: ___________ Date terminated: ________________________

Reason for leaving: _____________________________________________________________________

Employer:____________________________Supervisor:_________________________________

Address: ______________________________________ Phone #: _______________________________

Job title: ________________________ Hours per week: _______________________________________

Salary: ________ Per month Date hired: ___________ Date terminated: ________________________

Reason for leaving: _____________________________________________________________________

IIIb. Financial

What are your total assets: (cars, cash, property, homes, jewelry, tools, etc.) ________________________

Total:$

Total Debts: (credit cards, child support, medical bills, legal fees, loans):

Total:$

Vehicle Information of Vehicles you own or drive:

Make / Model Year Color License # and State

1.___________________________________________________________________________________

2.___________________________________________________________________________________

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MONTHLY INCOME (Approx.)

MONTHLY EXPENSES (Approx.)

Regular Job (+ tips)

$

Rent/House Payment

$

Part Time Job

$

Utilities

$

Spouse Income

$

Food/Clothing

$

Unemployment Comp.

$

Gasoline Etc.

$

Workman’s Comp.

$

Car Payment

$

Social Security

$

Car Insurance

$

Child Support/Alimony

$

Health Insurance

$

Welfare, TANIF, SNAP,

other government assistance

$

Child Care

$

Military Pension

$

Child Support/Alimony

$

Medical Bills

$

Credit Cards/loans

$

Court Fine/Fees

$

Cable/Satellite TV

$

Counseling

$

TOTAL

$

TOTAL

$

IV. Education:

Highest grade completed: __________

Do you have a high school diploma: No ( ) If Yes: school: _________________________ Year: ______

Do you have your GED: No ( ) Yes ( )

Did you attend College. No ( ) If yes: school: ________________________ Years completed: _____

Do you have a College Degree: No ( ) If yes: Type of Degree: _________________________________

Professional licenses or certificates: _______________________________________________________

Special Education Classes: No ( ) Yes ( )

Learning Disabilities: No ( ) Yes ( )

V. Military Service:

Military service branch: ___________________ Country: ________________

Rank at discharge: _____________________ Dates of service: From: ____________ To:_____________

Military duties / training: ________________________________________________________________

Type of discharge: ______________________Awards/ Medals: _________________________________

If no military service, did you register with the Selective Service /draft: No ( ) Yes ( )

VI. Physical Health:

How would you rate your health: Good ( ) Fair ( )Poor ( )

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Do you have anypresent or past serious, chronic diseases or illnesses, or any disabling medical problems,

Explain:

Are you receiving any medical treatment now: No ( ) Yes ( ) If Yes for what: _____________________

List all medications you are taking: ________________________________________________________

Do you possess a Valid Medical Marijuana Card: No ( ) Yes ( ) In what state: ____________________

If Yes for what: _______________________________________________________________________

Have you ever participated in mental health counseling: No ( ) Yes ( )

When and where: ______________________________________________________________________

What were you diagnosed with: ___________________________________________________________

Are you receiving any treatment now: ____ Name of therapist, Dr., or Psychologist:_________________

List all medications you are taking: ________________________________________________________

_____________________________________________________________________________________

Have you ever thought seriously about suicide or have you attempted suicide:

If yes, when, how, why?_________________________________________________________________

_____________________________________________________________________________________

VIII. Substance Abuse History:

Indicate your use of controlled substances below:

Substance Age first used Any recent use? When and How Often?

Alcohol

Marijuana

Methamphetamine

Cocaine/Crack

LSD / Acid

Ecstacy

Heroin

Mushrooms

Abuse of

Prescription Pills

Inhalants

Other (List)

How much do you spend on alcohol and/or drugs: Weekly: $________

Do you believe alcohol is a problem for you: No ( ) Yes ( )

Do you believe drugs are a problem for you: No ( ) Yes ( )

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Have you ever been in treatment: No ( ) Yes ( )

If Yes explain: (when, where, for what substance)____________________________________________

_____________________________________________________________________________________

What are you doing to address these issues now: ______________________________________________

_____________________________________________________________________________________

Were you under the influence when you committed the instant offense: No ( ) Yes ( )

Do you think gambling is a problem for you: No ( ) Yes ( )

How much do you spend weekly: $_________________

Have you ever been in treatment for gambling: No ( ) Yes ( )

Have you ever been on juvenile probation or parole: No ( ) Yes ( )

Date: ____________ Location: _________________ Phone number: _______________________

Name of last supervision officer: ____________________________________________________

Did you have any violations while on juvenile probation/parole: No ( ) Yes ( )

If Yes explain: __________________________________________________________________

_______________________________________________________________________________

Have you ever been on adult probation: No ( ) Yes ( )

Date: ____________ Location: _________________ Phone Number: _______________________

Name of last supervision officer: ____________________________________________________

Type of discharge: _______________________________________________________________

Did you have any violations while on probation: No ( ) Yes ( )

If Yes explain: __________________________________________________________________

_______________________________________________________________________________

Have you ever been in prison: No ( ) Yes ( )

Dates:_____________ Name of Prison and State: ______________________________________

Dates: _____________ Name of Prison and State: ______________________________________

Dates:______________ Name of Prison and State: ______________________________________

Have you ever been on adult parole: No ( ) Yes ( )

Date: ____________ Location: _________________ Phone number: _______________________

Name of last supervision officer: ____________________________________________________

Did you have any violations while on parole: No ( ) Yes ( )

If Yes explain: __________________________________________________________________

_______________________________________________________________________________

Have any members of your immediate familyever been in prison or on probation: No ( ) Yes ( )

If Yes explain: (Please include: who, when, where and for what crime)____________________________

_____________________________________________________________________________________

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Are you in a gang, or do you socialize with gang members: No ( ) Yes ( )

If Yes, what is the gangname and your moniker:______________________________________________

Are you a registered sex offender: No ( ) Yes ( )

XII. Present Offense:

How were you released from custody: ____________________ What facility: ______________________

Days in custody: __________.

Briefly describe the offense you committed:__________________________________________________

_____________________________________________________________________________________

Why did you commit this crime: __________________________________________________________

_____________________________________________________________________________________

Thinking back to the date of your criminal activity which resulted in this case, what, if anything would

you have done differently: ______________________________________________________________

_____________________________________________________________________________________

In your opinion, how do you believe this crime affected the victim: _______________________________

_____________________________________________________________________________________

How did this crime affect you: ____________________________________________________________

_____________________________________________________________________________________

What do you feel would be an appropriate penalty / consequences for your actions: _________________

_____________________________________________________________________________________

If you are eligible for and granted probation what is your plan:

Address: _________________________________________________Phone: ___________________

With whom do you plan to reside:_______________________________________________________

Employment: _________________________________

Address: _____________________________________

Is your current or potential employer aware of your current legal issues: No ( ) Yes ( )

What are your goals (treatment, programs, schooling)

__________________________________________________________________________________

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DEFENDANT’S STATEMENT

Write in your own words the circumstances of your offense, why you committed the offense, your present feelings about

your situation, and whyyou may be suitable for probation. A copy of this statement will be sent to the judge. Write or

print clearly. If using a pencil, please write as dark as possible. If you do not want to submit a written statement, still

initial that you acknowledge all changes to the PSI must be made prior to sentencing.

________________________________________________________________

Per Nevada Supreme Court opinion in Stockmeierv. State, anychanges to yourPresentence Investigation Report

must be made at or before sentencing. The information used in your Presentence Investigation Report may be

reviewed by federal, state and/or local agencies and used for future determinations to include, but not limited to,

parole consideration._____ (Defendant initials)

Signature ________________________________________ Date _______________________

Fillable Printable Presentence Investigation Report Form - Nevada

Fillable Printable Presentence Investigation Report Form - Nevada

Presentence Investigation Report Form - Nevada