FAMILY VIOLENCE EDUCATION PROGRAM APPLICATION, ORDERS AND DISPOSITION JD-FM-97 Rev. 10-11 C.G.S. § 46b-38c(h), 46b-38a; P.A. 11-152, sec. 4(i) TO: The Superior Court of the State of Connecticut Instructions To Person Applying for Program 1. Fill out the Application section and make 2 copies. 2. Send the Original to the Clerk of Court and one copy to the Prosecuting Attorney. 3. A $100 application fee, or an application for waiver of the fee (form JD-AP-48), must accompany this application. 4. Keep a copy for your records. www.jud.ct.gov The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. Application Name and Address of Accused (Number, Street, Town, and Zip Code) Docket Number CRName and Address of Court Crime(s) Charged (Name and Statute Number) I am applying for the Family Violence Education Program. 1. I have not already been convicted of a "family violence crime," as defined by the General Statutes, which happened on or after October 1, 1986. (See section 46b-38a of the Connecticut General Statutes for the definition of "family violence crime") 2. I have not had another case assigned to the Family Violence Education Program. 3. I have not used accelerated rehabilitation for a "family violence crime" which happened on or after October 1, 1986 (C.G.S. § 54-56e). 4. I am not charged with a class A, class B, or class C felony, or an unclassified felony or offense carrying a term of imprisonment of more than 10 (ten) years; and 5. ("X" if this applies to you) I am charged with a class D felony or an unclassified offense carrying a term of imprisonment of more than 5 (five) years. (If this box is checked, you must explain in writing why you think there is good cause to grant you this program. You must attach your explanation to this application.) If my application is granted, I agree to: 1. Giving the state more time to prosecute me (The tolling of any statute of limitations and to waive the right to a speedy trial with respect to the crime(s) with which I am charged); and 2. Pay to the court the fee for the Family Violence Education Program, except that if I am unable to pay, I will file with the court an affidavit of my inability to pay or indigency. If I file an affidavit of my inability to pay or indigency, the court may waive the program fee if it finds that I am unable to pay or indigent. ("X" one) I plan on claiming that I am unable to pay or that I am indigent. I plan to pay the program fee. Dismissal Application I also ask that if this application for family violence education is granted, and if I successfully finish the program and follow all the conditions set by the court, the court dismiss the charges against me. I ask that I be granted Family Violence Education under the General Statutes. I have read the above and understand it. I agree to the statements above and affirm that they are true under penalty of perjury. Date Signed Signed (Applicant) If Minor, Consented to By (Parent or Guardian) Date Signed Notice Unless good cause is shown, a person is not eligible to participate in the Family Violence Education Program if charged with a Class D felony or an unclassified offense carrying a term of imprisonment of more than 5 (five) years. First Order of Court The foregoing application is denied. The defendant is referred to the Family Violence Intervention Unit, and this case is continued pending the submission of the report of the unit to the court and to the date indicated below. Court Hearing Date and Time Signed (Judge/Assistant Clerk) Date Signed For Court Use Only Date of Family Violence Intervention Unit Report Date Victim Notified (Use form JD-FM-96) Affidavit of inability to pay or indigency Yes No Date Filed To Continuances (If Any) To (continued...) Family Violence Education Program - Application, Orders, and Disposition American LegalNet, Inc. www.FormsWorkFlow.com Oath (Optional with the Court) The applicant appeared before the undersigned individual, designated by the clerk and duly authorized to administer oaths, and confirmed, under penalties of perjury, the statements made in the application and any statements attached to the application containing the reasons why the applicant believes good cause exists to invoke the program even though the applicant is charged with a class D felony or an unclassified offense carrying a term of imprisonment of more than five years. Title Signed (Clerk's Designate, Duly Authorized) Date Second Order of Court THE COURT, having considered the foregoing application, the report of the Family Violence Intervention Unit and the statement(s), if any, of the victim(s) hereby finds: That the applicant is eligible for assignment to the Family Violence Education Program. That the applicant is charged with a class D felony or an unclassified offense carrying a term of imprisonment of more than five years and that good cause exists to invoke this program on behalf of such applicant. That the applicant is NOT eligible for assignment to the Family Violence Education Program. WHEREFORE, the court orders: The foregoing application is DENIED. The foregoing application is GRANTED and the accused is released to the custody of the Family Violence Intervention Unit for the period indicated below. The following conditions are also imposed: The court denies the application for waiver of fee. FEE PAID Clerk's Initials The accused is ordered to pay the clerk forthwith the applicable program fee. Date The court waives the fee having found that the applicant is indigent or unable to pay. Case Continued To (Date and Time) Date Signed (Judge/Assistant Clerk) Disposition (Complete One Side Only) Program Not Successfully Completed Program Successfully Completed and Charges Dismissed Signed (Judge/Assistant Clerk) Conditions Not Complied With Date Signed (Judge/Assistant Clerk) Date JD-FM-97 (Back) Rev. 10-11 American LegalNet, Inc. www.FormsWorkFlow.com