Court-Ordered Program Discharge Form
Please complete this form to request discharge from the court-ordered program.
Full Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Case Number
Program Name
Date of Program Enrollment
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Discharge Request
Discharge Effective Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: