Fill and Sign the Cis Coordinators by Districtdepartment for Children Vermont Dcf Form

County Diversion Programs ADDISON 282 Boardman Street PO Box 881 Middlebury, VT 05753 802-388-3888 BENNINGTON 439 Main Street Bennington, VT 05201 802-447-1595 CALEDONIA 24 Bagley Street St. Johnsbury, VT 05819 802-748-8732 CHITTENDEN 200 Church Street Burlington, VT 05401 802-865-7155 ESSEX 24 Bagley Street St. Johnsbury, VT 05819 802-748-8732 FRANKLIN 120 N. Main St. St. Albans, VT 05478 802-524-7006 GRAND ISLE 120 N. Main St. St. Albans, VT 05478 802-524-7006 LAMOILLE 221 Main Street PO Box 148 Hyde Park, VT 05655 802-888-5871 ORANGE PO Box 58 Chelsea, VT 05038 802-685-3172 ORLEANS 71 Seymour Lane Newport, VT 05855 802-334-8224 RUTLAND 50 Center Street Rutland, VT 05701 802-786-3840 WASHINGTON 322 North Main Street, Suite 5 Barre, Vermont 05641 Phone: 802 479-1900 NOTICE OF VIOLATION You are being charged with a violation of law as indicated below. ______Minors Misrepresenting Age, Procuring, Possessing or Consuming Alcoholic Beverages (7 V.S.A. Section 656) Complaint #_______________________________ AND OR ______Marijuana Possession by a Person under 21 Years of Age, one ounce or less (18 V.S.A. Section 4230b) Complaint #_______________________________ 1. As required by law, you must provide this officer with your correct name and mailing address. Please also give the officer your telephone number. 2. Within 15 DAYS, you must contact the County Diversion’s Youth Substance Abuse Safety Program (YSASP) at the address or phone number circled to your left. 3. Do not send any money to pay any legal penalty at this time. There is a program fee required by the YSASP. 4. Until you have finished all conditions of the program, you must inform the YSASP office of any changes in your name or address. If you contact the Youth Substance Abuse Program within 15 days and complete all conditions of the program, this violation will be voided, and no penalty will be imposed. There is a program fee. The fee may be reduced based on your circumstances and paid in installments. The Youth Substance Abuse Safety Program involves participating in a screening process about your substance use and discussing your use with a YSASP case manager. You may need to complete an assessment with a substance use clinician and follow their recommendations for treatment. If you are under age 18, a legal guardian must give permission for you to participate in the program. If you fail to contact the Youth Substance Abuse Program within 15 days or fail to complete all conditions of the program, the ticket for this violation will be issued. At that time, you may contest the charge with the Judicial Bureau. WINDHAM 32 Walnut Street Brattleboro, VT 05302 802-257-0361 WINDSOR 211 North Main Street PO Box 474 White River Jct, VT 05001 802-295-5078 If the Judicial Bureau finds you in violation, you will have to pay a fine and your privilege to operate a motor vehicle in Vermont will be suspended. The cost of your car insurance may increase substantially. If you hold a license from another state, that state will revoke your privilege to operate a vehicle also. You may have other tickets or citations. For example, if you were driving, you may have been given a ticket or criminal citation for operating a vehicle under the influence. Address your response to those tickets or citations to the Judicial Bureau or State’s Attorney as explained on those documents. __________________________________________________________________ Law Enforcement Officer Phone # Department Name Date of violation _____________________ 500-00421 – Notice of Violation (07/2019) Page 1 of 1