PRE-TRIAL ALCOHOL EDUCATION PROGRAM Instructions To Person Filling Out This Application 1. File the original of this application with the clerk of court. 2. Send a copy to the prosecuting attorney. 3. A $100 application fee and a nonrefundable $100 evaluation fee, or an application for waiver of the fees, must be filed with this application. APPLICATION, ORDER JD-CR-44 Rev. 2-11 C.G.S. § 14-227a, 14-227g, 54-56g www.jud.ct.gov CSSD Case Number TO: The Superior Court of the State of Connecticut Docket Number Geographical Address of Court Area Number Name of Applicant/Defendant Operator's Number/Issuing State Social Security Number Date of Birth Telephone Number Address of Applicant (Number, street, town, apartment number and zip code) I am charged with operating a motor vehicle while under the influence of liquor or drug or while having an elevated blood alcohol content; being under 21 (twenty-one years of age) and operating a motor vehicle while my blood alcohol content was more than .02% (twohundredths of one per cent); operating a vessel while under the influence of liquor or drugs; recklessly operating a vessel in the 1st degree while under the influence of intoxicating liquor or drugs; recklessly operating a vessel in the 2nd degree; or manslaughter in the 2nd degree with a vessel (in violation of sections 14-227a, 14-227g, 15-132a, 15-140l or 15-140n of the Connecticut General Statutes). I am applying for the Pre-Trial Alcohol Education Program. If my application is granted: 1. I agree to give the state more time to prosecute me for this charge (the tolling of any statute of limitations with respect to this violation and to waive my right to a speedy trial). 2. I agree to begin my 10 or 15 counseling sessions in an alcohol intervention program or substance abuse treatment program, according to the evaluation report and the court order, within 90 days from the day the court orders me to, unless I am granted a delayed entry; and I agree to finish the alcohol intervention program or substance abuse treatment program of at least 12 sessions; and when I finish the alcohol intervention program, to be placed in a treatment program recommended by a provider under contract with the Department of Mental Health and Addiction Services (DMHAS) or to be placed in a state-licensed treatment program which meets standards set by DMHAS if the Court Support Services Division (CSSD) decides I should. 3. I agree to participate in at least 1 (one) victim impact panel if the court orders me to. 4. If I decide to enter the program after the suspension of my license is over, I agree to tell CSSD the date my license was suspended and how long my license was suspended for. 5. I agree to pay the court a nonrefundable program fee of $350 if I am ordered into the 10 session alcohol intervention program, or $500 if I am ordered into the 15 session alcohol intervention program (these fees may be changed by the legislature), or to pay the costs of being in a treatment program if I am ordered into a treatment program, except that if I cannot pay or if I am indigent, I will file with the court an affidavit saying I cannot pay or that I am indigent. I give my permission to CSSD to get information about any criminal or motor vehicle program I may have been in in this state or in any other jurisdiction so that CSSD can decide if I can be accepted into the program. If I am telling the court that I cannot pay or that I am indigent by filing an affidavit of my inability to pay or of my indigency, I give my permission to CSSD to get information to decide if I cannot pay or if I am indigent. ("X" one of the following) I intend to claim an inability to pay or indigency I intend to pay the program fee. By signing this form, I am saying that I understand all of the above and I request that I be granted Pre-Trial Alcohol Education (section 54-56g of the Connecticut General Statutes). I have read this entire application and I understand it. Notice Signed (Applicant) Date Signed Consented to By (Parent or guardian) Unless good cause is shown, a person is not eligible for the Pre-Trial Alcohol Education Program if the alleged violation of section 14-227a or 14-227g caused the serious physical injury, as defined in section 53a-3, of another person. Oath The applicant stated under penalties of perjury before me, duly designated by the clerk and authorized to administer oaths, that (1) if (s)he is charged with a violation of section 14-227a of the after October 1, 1981, or a violation of subdivision (1) or (2) of Connecticut General Statutes, (s)he has not had the Pre-Trial subsection (a) of section 14-227a of the Connecticut General Alcohol Education Program invoked in his/her behalf within the Statutes on or after October 1, 1985, and that (s)he has not been preceding ten (10) years for a violation of section 14-227a of the convicted in any other state at any time of an offense the Connecticut General Statutes, essential elements of which are substantially the same as (2) if (s)he is charged with a violation of section 14-227g of the sections 53a-56b or 53a-60d or subdivision (1) or (2) of Connecticut General Statutes, (s)he has never had the Pre-Trial subsection (a) of section 14-227a of the Connecticut General Alcohol Education Program invoked in his/her behalf for a violation Statutes, and of section 14-227a or section 14-227g of the Connecticut General (3) if (s)he is charged with a violation of section 14-227a of the Statutes, and that (s)he has not been convicted of a violation of Connecticut General Statutes, (s)he was not operating a sections 53a-56b or 53a-60d, a violation of subsection (a) of commercial motor vehicle as that term is defined in section 14-1 section 14-227a of the Connecticut General Statutes before or of the Connecticut General Statutes. Signed (Duly authorized person) Print Name of Person Signing at Left (Continued...) Date Signed American LegalNet, Inc. www.FormsWorkFlow.com First Order of Court ("X" all that apply) The application is denied. The court waives the following fee(s) or portion of fees having found that the applicant is indigent or unable to pay: Application fee: all ; $ Evaluation fee: all ; $ The applicant's oath under section 54-56g of the Connecticut General Statutes was taken: ("X" one) in open court. outside of court by a person duly designated by the clerk and authorized to administer oaths. The case is continued until the date and time listed below to consider the Court Support Services Division assessment of eligibility and the Department of Mental Health and Addiction Services evaluation and/or for the applicant to file an affidavit of indigency and for the Court Support Services Division to seek to confirm such indigency. The Court orders the court file sealed as to the public. Case Continued To (Date and time) Date Signed Signed (Judge, Assistant Clerk) Court Support Services Division Assessment and Confirmation Out-of-state D.W.I. Conviction Chemical Analysis Results (Specify BAC) Yes Prior section 14-227a Conviction No Yes No Prior section 14-227g Conviction Yes No Charged With Violating section 14-227a While Operating a Commercial Motor Vehicle Yes Applicant did not attend evaluation appointment No Prior Program Participation Yes, date: Able to Pay Program Fee No Yes DHMAS Evaluation Recommendation (Report attached) 10 Session Alcohol 15 Session Alcohol Assessment No (Affidavit attached) Substance Abuse Treatment Eligible Ineligible Signed (CSSD Officer) Second Order of Court (If the application is denied and the file ordered unsealed, consider ordering the applicant's social security number, date of birth and telephone number redacted.) The court, having determined that the applicant is ineligible, denies the application and the court file is ordered to be unsealed, a plea of not guilty entered and this case is to be immediately placed on the trial list. The application is granted and the applicant is referred to the Court Support Services Division for referral to the Department of Mental Health and Addiction Services for placement in an appropriate alcohol intervention program for one year or to be placed in a state-licensed substance abuse treatment program. The applicant has opted to enter the program: . not later than 90 days after the date of this order. The defendant may begin the program by when the period of the applicant's license suspension pursuant to section 14-227b of the Connecticut General Statutes, is completed. The applicant is ordered to notify the Court Support Services Division of the date the applicant's license was suspended and the length of the suspension. The defendant shall participate in one victim impact panel. The program fee is: $350 (10 sessions) $500 (15 sessions) and the defendant is ordered to forthwith pay the clerk the nonrefundable program fee unless the fee is waived below. The court denies the application for waiver of fees and the defendant is ordered to pay to the clerk forthwith the statutory program fee. The court waives the following portion of fee having found that the defendant is indigent or unable to pay: all ; $___________. The substance abuse treatment program costs shall be paid by the defendant unless the costs are ordered paid by the state below. The court denies the application for waiver of costs and the defendant is ordered to pay all costs associated with participation in the substance abuse treatment program. The court waives the defendant's obligation to pay the cost of participation in the treatment program and the costs of the treatment program shall be paid from the pretrial account established under section 54-56k of the Connecticut General Statutes, having found the defendant is indigent or unable to pay. Case Continued To (Date and time) Signed (Judge, Assistant Clerk) Date Signed Third Order of Court (If motion for extension filed) The defendant's motion for extension of the one-year placement period to complete the assigned program: is DENIED. is GRANTED. The period is extended to the date shown below, the defendant having established good cause for such extension. Case Continued To (Date and time) Signed (Judge, Assistant Clerk) Date Signed JD-CR-44 (Back) Rev. 2-11 American LegalNet, Inc. www.FormsWorkFlow.com