PRE-TRIAL DRUG EDUCATION PROGRAM APPLICATION, ORDER JD-CR-118 Rev. 7-12 C.G.S. § 54-56i Instructions 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. Notice To Clerk: Seal the file on order of the court per C.G.S.§ 54-56i(b). 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. To: The Superior Court of the State of Connecticut Geographical Address of court Area number CMIS case number Name of Applicant/Defendant Last 4 digits of Social Security number XXX-XX- Docket number Address of Applicant (Number, street, town, apartment number and zip code) Telephone number Date of birth I have been charged with violating drug paraphernalia laws or drug possession laws (under section 21a-267 or section 21a-279 of the Connecticut General Statutes), and apply for the Pre-Trial Drug Education Program. I agree, if my application is granted, 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 such crime(s) if I do not successfully complete the Program. 2. To begin my participation in the drug education program within 90 days from the day the court orders me to unless I am granted a delayed entry and I agree to complete participation in 10 or 15 sessions of the drug intervention program or substance abuse treatment program as recommended by the evaluation ordered by the court and after finishing the program, to accept treatment in a treatment program recommended by a DMHAS contractor or take part in a treatment program that has standards that are like or higher than the DMHAS contractor's program if the Court Support Services Division thinks I should. 3. To any conditions that may be set up by the Department of Mental Health and Addiction Services (DMHAS) concerning my taking part in the drug education program including conditions concerning my taking part in meetings or sessions of the program. (Section 53a-39c of the Connecticut General Statutes.) 4. That I take part in a community service labor program for at least 5 days if I am in a 10-session drug intervention program or a substance abuse treatment program; and if I am in a 15session drug intervention program that I take part in a community service labor program for at least 10 days. (Section 53a-39c of the Connecticut General Statutes). 5. To pay the court a non-refundable fee of $350 ( as may be changed by the legislature) to take part in the 10-session drug intervention program or $500 ( as may be changed by the legislature) to take part in the 15-session drug intervention program. I must pay for the costs of the substance abuse treatment program if I am ordered to participate 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 the Court Support Services Division to get information about my prior participation in the Pre-Trial Drug Education Program and the Pre-Trial Community Service Labor Program in order to confirm that I am eligible for the Pre-Trial Drug Education Program. If I file an affidavit of inability to pay or indigency, the Court Support Services Division 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 intend to claim an inability to pay or indigency. I intend to pay the program fee. By signing this form, I request that I be granted the Pre-Trial Drug Education Program (Section 54-56i of the Connecticut General Statutes). I have read the above and understand it. Signed (Applicant) Date signed Consented to by (Parent or Guardian) Ź Oath The applicant stated under penalties of perjury before me, duly designated by the clerk and authorized to administer oaths, that (s)he has never previously participated in the Drug Education Program established under section 54-56i of the general statutes or the pre-trial community service labor program established under section 53a-39c of the Connecticut General Statutes. Signed (Duly authorized person) Print name of person signing at left Date signed ("X" All that apply) (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 applicant's oath under section 54-56i of the Connecticut General Statutes The application is denied. was taken in open court. The application is granted. The court orders the court file sealed as to the public and refers the applicant to the Court Support Services Division for assessment and confirmation of the eligibility of the applicant and to DMHAS to evaluate the applicant. First Order Of Court The case is continued until (date) _________________at (time) ___________a.m./p.m. to permit the Court Support Services Division to process the filed affidavit of indigency or inability to pay. Case continued to (Date and time) Signed (Judge, Assistant Clerk) (Page 1 of 2) Date signed American LegalNet, Inc. www.FormsWorkFlow.com Court Support Services Assessment And Confirmation Prior CSLP Prior program participation YES NO YES Able to pay program fee NO DHMAS evaluation recommendation (Report attached) 10 Session Drug 15 Session Drug YES NO Substance Abuse Treatment Assessment PARTIAL ELIGIBLE INELIGIBLE Signed (C.S.S.D. Officer) Second Order Of Court (If assessed ineligible or claim of indigency) (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 to be immediately placed on the trial list. The application is granted and the defendant is referred to the Court Support Services Division for referral to the Department of Mental Health and Addiction Services for placement in a 10-session or 15-session drug intervention program or a substance abuse treatment program and if the defendant is placed in a 10-session drug intervention program or a substance abuse treatment program, the defendant must also take part in at least a 5-day community service labor program or if the defendant is placed in a 15-session drug intervention program, the defendant must take part in at least a 10-day community service labor program. (Section 53a-39c of the Connecticut General Statutes). The defendant is to forthwith pay the clerk a nonrefundable program fee of: $350 (10 sessions) $500 (15 sessions) 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 fee having found that the defendant is indigent or unable to pay. The court waives a portion of the fee, having found that the defendant is unable to pay the full fee. The defendant is ordered to pay the clerk forthwith $ _____________________ as payment for the program fee. 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 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 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 Fourth Order Of Court (If request to attend out-of-state program) The defendant's request to attend a program in another state that has standards similar to, or higher than, those of Connecticut, due to the defendant's employment or residence or schooling making it unreasonable to attend a drug program in Connecticut: is Granted, subject to the payment of the program fee provided by statute unless the fee is waived above (see second order of the court). is Denied. Case continued to (Date and time) JD-CR-118 (Page 2 of 2) Rev. 7-12 Signed (Judge, Assistant Clerk) Date signed American LegalNet, Inc. www.FormsWorkFlow.com