MIP DIVERSION PETITION AND AGREEMENTMip Diversion Agreement • December 13th, 2018
Petitioner is to provide the information required in this box, as follows (print or type): Petitioner’s name/residence: First Middle Last Street City State Zip Petitioner’s date of birth Month Day Year Petitioner’s mailing address: Street City State Zip ( ) Telephone No. Petitioner’s driver license no. License No. State Court where the charge was filed and petition is to be submitted: Benton County Court Case Number Date of MIP offense Month Day Year
