PRETRIAL DRUG EDUCATION AND COMMUNITY SERVICE PROGRAM APPLICATION JD-CR-118 Rev. 10-16 C.G.S. § 54-56i; P.A. 16-167 § 45 STATE OF CONNECTICUT SUPERIOR COURT JUDICIAL BRANCH www.jud.ct.gov Instructions to Defendant 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 $150 evaluation fee, or an application for waiver of the fees, must be filed with this application. Notice To Clerk: Seal the file on order of the court per C.G.S. § 54-56i(b). TO: The Superior Court of the State of Connecticut GA/JD number Address of court 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. Docket number ADA Notice Name of defendant Alias/Maiden name of defendant Offense(s) charged Address of defendant (Number, street, apartment number, town, and zip code) Telephone number of defendant CMIS case number Prior Participation Have you previously been allowed into the Pretrial Drug Education Program that was in effect before October 1, 2013, the Community Service Labor Yes No Program, or the Pretrial Drug Education and Community Service Program? If yes, how many times have you been allowed into any of these programs? 1 2 3 or more. Military Status Have you ever served in the U.S. Armed Forces, including the Connecticut National Guard Yes No (as defined in section 27-103 of the Connecticut General Statutes)? If you have ever served in the armed forces: ("X" one) I am an active member of the armed forces. I 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. Application I have been charged with violating drug paraphernalia laws or drug possession laws under section 21a-267, 21a-279, or 21a-279a of the Connecticut General Statutes, and apply for the Pretrial Drug Education and Community Service Program. If my application is granted, I agree to the following: 1. To give the state more time to prosecute me (the tolling of any statute of limitations and waiver of the right to a speedy trial) for the offense(s) listed above if I do not successfully complete the Program. 2. To begin the Drug Education Program within 90 days of the day that the court orders me into the program, unless the court gives me more time to start the program. I understand that the court will order an evaluation of me that will determine whether I have to go to 15 sessions of a drug education program or at least 15 sessions of a substance abuse treatment program. After finishing the program that the court orders me into, if the Court Support Services Division (CSSD) thinks I need more treatment, I agree to accept any additional treatment in a treatment program recommended by a Department of Mental Health and Addiction Services (DMHAS) contractor, or the Connecticut Department of Veterans Affairs or the United States Department of Veterans Affairs if I am a veteran and either of those organizations are treating me, or to go into another treatment program that has standards that are at least as high or higher than the DMHAS contractor's program. 3. To follow any conditions that may be set up by DMHAS, the Connecticut Department of Veterans Affairs, or the United States Department of Veterans Affairs, concerning my taking part in the drug education program including conditions concerning my taking part in meetings or sessions of the program. 4. That I will take part in a community service labor program set up under section 53a-39c of the Connecticut General Statutes for at least five days if this is the first time that I have been allowed into the drug education and community service program, at least 15 days if this is second time that I have been allowed into the program, or at least 30 days if this is the third or additional time that I have been allowed into the program. 5. To pay the court a non-refundable fee of $600 (as may be changed by the legislature) to take part in the drug education program or $100 (as may be changed by the legislature) to take part in a substance abuse treatment program. I understand that I must also pay for the costs of the substance abuse treatment program if I am ordered to take part in that program. If I cannot pay or am indigent, I will file with the court an affidavit telling the court why I cannot pay. I give my permission to CSSD to get information about my prior participation in the Pretrial Drug Education Program, the Pretrial Drug Education and Community Service Program, and the Community Service Labor Program in order to confirm that I am eligible for the Pretrial Drug Education and Community Service Program. If I file an affidavit of inability to pay or indigency, CSSD will look into whether I can pay, and the court may decide that I do not have to pay all or any part of the program fee if it finds that I am indigent or unable to pay the fee to take part in this program. ("X" one of the following) I plan to claim that I cannot pay or that I am indigent. I plan to pay the program fee(s). By signing this form, I request that I be allowed into the Pretrial Drug Education and Community Service Program under section 54-56i of the Connecticut General Statutes. I have read the above information and understand it. Signed (Duly authorized person) Signed (Defendant) Print name Date signed Consented to by (Parent or Guardian) Date signed (Page 1 of 2) American LegalNet, Inc. www.FormsWorkFlow.com Order of the Court ("X" All that apply) The application is denied. The application is granted. The court orders the court filed sealed as to the public, refers the defendant to CSSD for confirmation of the defendant's eligibility, and: As this is the first or second time that the defendant's application has been granted, the defendant is referred to DMHAS for evaluation and determination of an appropriate drug education or substance abuse treatment program. As the defendant is a veteran, and as this is the first or second time that the defendant's application has been granted, the defendant is referred for evaluation and determination of an appropriate drug education or substance abuse treatment program to: DMHAS Connecticut Department of Veterans Affairs United States Department of