D:\_data\wp\docs\completion certificates - ps\el_paso_antabuse_ps.frm

COUNTY COURT, COUNTY OF EL PASO, COLORADO
Court Address: 20 East Vermijo Ave. Room 105
PO Box 2980 Colorado Springs, CO 80901-2980 Plaintiff:
PEOPLE OF THE STATE OF COLORADO
-v-
Defendant(s):
• COURT USE ONLY •
Case No: ___ T _______
CERTIFICATE OF COMPLETION
STATE OF 9 COLORADO 9 __________________________ COUNTY OF 9 EL PASO 9 TELLER 9 __________________ Court order regarding disulfiram - aka antabuse: 9 none to date 9 ____ x per week from ______________, 20___ through from ______________, 20___ Completion proof to be filed on or before: ______________, 20___ 9 monthly 9 quarterly * * * * * * * * * * * * * * * * * * * * * * * * SIGNATURE OF VERIFIER'S VERIFIER'S DATE PERSON GIVING PRINTED PHONE ANTABUSE VERIFICATION NAME OR AGENCY NUMBER TAKEN * * * * * * * * * * * * * * * * * * * * * * * * 1. ____________________ ____________________ (____) _________ _________, 20___ 2. ____________________ ____________________ (____) _________ _________, 20___ 3. ____________________ ____________________ (____) _________ _________, 20___ 4. ____________________ ____________________ (____) _________ _________, 20___ 5. ____________________ ____________________ (____) _________ _________, 20___ 6. ____________________ ____________________ (____) _________ _________, 20___ 7. ____________________ ____________________ (____) _________ _________, 20___ 8. ____________________ ____________________ (____) _________ _________, 20___ 9. ____________________ ____________________ (____) _________ _________, 20___ 10. ____________________ ____________________ (____) _________ _________, 20___ 11. ____________________ ____________________ (____) _________ _________, 20___ 12. ____________________ ____________________ (____) _________ _________, 20___ 13. ____________________ ____________________ (____) _________ _________, 20___ 14. ____________________ ____________________ (____) _________ _________, 20___ 15. ____________________ ____________________ (____) _________ _________, 20___ 16. ____________________ ____________________ (____) _________ _________, 20___ 17. ____________________ ____________________ (____) _________ _________, 20___ 18. ____________________ ____________________ (____) _________ _________, 20___ 19. ____________________ ____________________ (____) _________ _________, 20___ 20. ____________________ ____________________ (____) _________ _________, 20___ 21. ____________________ ____________________ (____) _________ _________, 20___ 22. ____________________ ____________________ (____) _________ _________, 20___ 23. ____________________ ____________________ (____) _________ _________, 20___ 24. ____________________ ____________________ (____) _________ _________, 20___ 25. ____________________ ____________________ (____) _________ _________, 20___ I ACKNOWLEDGE THAT THE ABOVE INFORMATION IS CORRECT ____________________________________Defendant’s Signature INSTRUCTIONS RE COMPLETION PROOF
When completed - mail or file this form directly with the Clerk of Court - address in above caption DEFENDANT KEEP A COPY IN YOUR PERSONAL RECORDS FOR 5 YEARS
Form provided as courtesy via internet www.gustafsonlaw.com - posted to website May 20, 2005
Robert D. Gustafson - Colorado Attorney Registration No. 10930 6538 Charter Drive, Colorado Springs, CO 80918 Ph: (719) 260-1002 Fax (719) 260-1002 Use of this public form shall neither constitute representation nor appearance of counsel This is a public form - no attorney representation is made pursuant to C.R.Civ.P. §§ 11(b) or 311(b)

Source: http://virtual2.pcisys.net/g/gustafsonlaw.com/PDF/Crim-DUI-Traffic/DUI-LOC-PS/El_Paso_Antabuse_PS.pdf