Page 1 of 2APPLICATION FOR ACCELERATED PRETRIAL REHABILITATION JD-CR-9 Rev. 7-19 C.G.S. 247 54-56e; P.B. 247 39-33Instructions to Person Filing the Application 1. Fill out the Application and Military Status sections of the form and sign it. 2. Give the original form to the Clerk of Court, and keep a copy for your records. 3. Send a copy to the prosecuting attorney (the State222s Attorney for your case). 4. A $35.00 application fee or an Affidavit of Indigency - Fee Waiver, Criminal (form JD-AP-48) must be filed with this application.I plan to pay the $100 program fee or the $425 program fee, if ordered to.I am charged with the offense(s) listed above, and I am applying for Accelerated Pretrial Rehabilitation. I agree with the following statements: 1. The offense(s) that I am charged with could result in a sentence of imprisonment. The offense(s) do not include: (A) a class A felony; (B) a class B felony, except a violation of section 53a-122 (a) (1), (2), or (3) of the Connecticut General Statutes that does not involve the use, attempted use, or threatened use of physical force against another person, or a violation of section 53a-122 (a) (4) that does not involve the use, attempted use, or threatened use of physical force against another person and does not involve a violation by a person who is a public official or a state or municipal employee as those terms are defined in section 1-110; (C) a violation of section(s) 9-359, 9-359a, 14-227a, 53-21 (a) (2), 53a-56b, 53a-60 (a) (6), 53a-60d, 53a-70, 53a-70a, 53a-70b, 53a-71 (except as provided in section 54-56e (c) (5)), 53a-72a, 53a-72b, 53a-90a, 53a-196e, or 53a-196f of the Connecticut General Statutes; (D) a crime or motor vehicle violation that caused the death of another person; (E) a family violence crime as defined in section 46b-38a of the Connecticut General Statutes if: (i) I am eligible for the pretrial family violence education program under section 46b-36c, or (ii) I have already had the pretrial family violence education program; (F) a violation of section 21a-267 or 21a-279 of the Connecticut General Statutes if: (i) I am eligible for the pretrial drug education and community service program under section 54-56i of the Connecticut General Statutes, or (ii) I have already had the pretrial drug education program or the pretrial drug education and community service program; (G) a motor vehicle violation, while, at the time of the violation: (i) I was operating a commercial vehicle as defined in section 14-1 of the Connecticut General Statutes, or (ii) I held a commercial driver's license or commercial driver's instruction permit; or (H) a violation of section 53a-122 or 53a-123 (a) (4) while I was a provider or vendor taking part in the state's Medicaid program. 2. If the offense(s) that I am charged with are a class C felony or are a violation of section 53a-71 (a) (1) of the Connecticut General Statutes, where I was less than four years older than the other person, there is good cause for granting this application. 3. I have never been convicted of a crime or of a violation of section 14-196, 14-215 (c), 14-222a, 14-224 (a), 14-224 (b) (1), 14-227a, 14-227m, or 14-227n (a) (1) or (2) of the Connecticut General Statutes. 4. I give the state more time to prosecute me (the240tolling of any statute of limitations and the waiver of the right to a speedy trial) for the offense(s) listed above, if I do not successfully complete this program. 5. I will give the victim(s) of these offense(s) notice of this Application so that the victim(s) will have an opportunity to tell the Court what they think about this application. 6. If this application is granted, I agree that any physical evidence being held by the police may, at the discretion of the Court, be returned to the rightful owner before the end of the case. I also agree that, if the case must eventually be tried, secondary evidence, such as photographs of the physical evidence, may be admitted into evidence instead of the physical evidence. 7. If this application is granted, I will pay the Court a participation fee of $100, or, if I am ordered to take part in a Hate Crimes Diversion Program, a participation fee of $425, except that, if I cannot pay or I am indigent, I will file with the Court an affidavit saying that I cannot pay or that I am indigent, and the Court may decide that I do not have to pay the program fee if it finds that I am unable to pay either the $100 fee or the $425 fee or that I am indigent. ("X" one of the following)I plan to claim that I cannot pay or that I am indigent. Instructions to Clerk 1. Seal file on order of the Court per C.G.S. 247 54-56e. 2. Send a copy of the application to CSSD.Application CMIS case number Docket number Telephone number of defendant Address of Court Name of defendant Address of defendant (Number, street, apartment number, town, and zip code) GA/JD number TO: The Superior Court of the State of Connecticut Alias/Maiden name of defendant Offense(s) charged STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov ADA Notice 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.Continued on next page... File date For Court Use Only American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2Have you ever served in the U.S. Armed Forces, including the Connecticut National Guard (as defined in section 27-103 of the Connecticut General Statutes)? Court hearing date and timeIf you have ever served in the armed forces: (223X224 one)JD-CR-9 Rev. 7-19 The Application is continued to the Court Hearing Date listed below, and the defendant is referred to the Court Support Services Division for a determination of eligibility and a confirmation of inability to pay or indigency if the defendant has filed an affidavit claiming an inability to pay or indigency. The defendant must also send notice to any victim(s) of his or her offense(s) telling them of the opportunity to tell the Court whether they think the Court should grant the application. This notice must be sent on form JD-CR-10 by Registered or Certified Mail on or before the Notice Date listed below. Signed (Judge or Assistant Clerk) Notice date Date signedThe Application is denied.First Order of the Court The Court orders the court file sealed as to the public. The defendant stated under penalties of perjury before me, duly designated by the clerk and authorized to administer oaths, that he or she never has never used this program before, that he or she used this program only once before for a misdemeanor or a motor vehicle violation that had a potential penalty of 1 year of imprisonment or less, and at least 10 years have gone by since that charge was dismissed, or that he or she is a veteran (a person who was discharged or released under conditions other than dishonorable from active service in the armed forces as defined in section 27-103 of the Connecticut General Statutes), and has only used this program once before. Signed (Assistant Clerk/Duly authorized person) Date signed Oath The defendant's oath under section 54-56e of the Connecticut General Statutes was taken ("X" one): In open court.Outside of court by a person designated by the clerk and duly authorized to administer oaths.By signing this form, I am saying that I understand all of the information included on this form, and I request that I be allowed into Accelerated Pretrial Rehabilitation under section 54-56e of the Connecticut General Statutes.Military Status YesNoI am an active member of the armed forces. Print nameI was discharged or released from active service in the armed forces honorably or under conditions other than dishonorable. I was dishonorably discharged from active service in the armed forces. Signed (Defendant) I have read the above information and understand it. Consented to by (Parent or Guardian) Date signed Date signed Signed (Duly authorized person) Print name American LegalNet, Inc. www.FormsWorkFlow.com