PRETRIAL DRUG EDUCATION AND COMMUNITY SERVICE PROGRAM REQUEST FOR REINSTATEMENT JD-CR-118R Rev. 10-16 C.G.S. § 54-56i; P.A. 16-167 § 45 STATE OF CONNECTICUT SUPERIOR COURT JUDICIAL BRANCH www.jud.ct.gov ADA Notice Instructions To Person Filling Out This Application 1. File the original of this application with the clerk of the court. 2. Send a copy to the prosecuting attorney. 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 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 I have applied for the Pretrial Drug Education Program or the Pretrial Drug Education and Community Service Program before, and my application was granted. I was placed in this program but I did not successfully complete the program assigned to me or I was found to be no longer amendable to treatment. I now request reinstatement into the Pretrial Drug Education and Community Service Program. If my request is granted, I understand that I must pay a nonrefundable program fee of $250, which will not be waived unless the court finds good cause (a reason why I should not have to pay). I understand that I may also need to pay the costs of reinstatement into the program, if any. Signed (Defendant) Print name Date signed Court Support Services Division Verification of Eligibility Eligible for reinstatement Ineligible for reinstatement If granted, this is defendant's first reinstatement to this program. If granted, this is defendant's second reinstatement to this program. Drug Education Program recommended (15 sessions). Substance Abuse Treatment Program recommended (No less than 15 sessions). Signed (Bail Services staff) Print name Next court date Date signed Court Order ("X" all that apply) (If the application is denied and the file ordered unsealed, consider ordering the applicant's telephone number redacted.) The request for reinstatement is denied, and the court file is ordered to be unsealed, a plea of not guilty is entered, if not previously entered, and this case is to be immediately placed on the trial list. The request for reinstatement is granted, the court file is ordered sealed, and the defendant is referred to the Court Support Services Division for referral to the Department of Mental Health and Addiction Services, the Connecticut Department of Veterans Affairs, or the United States Department of Veterans Affairs, as appropriate, for placement in an appropriate drug education program for one year, which includes the community service labor program participation requirement, or to be placed in a state-licensed substance abuse treatment program, or a substance abuse treatment program with the Connecticut Department of Veterans Affairs, or the United States Department of Veterans Affairs, as appropriate, which also includes the community service labor program participation requirement. The defendant is ordered to enter the assigned drug education or substance abuse treatment program without delay. The drug education program fee is $250, and the defendant is ordered to pay the clerk the nonrefundable program fee, unless the fee is waived below. The program fee is waived for good cause shown. The substance abuse treatment program costs shall be paid by the defendant unless the costs are waived below. The costs of placement in a substance abuse treatment program is waived for good cause shown. Case continued to (Date and time) Signed (Judge, Assistant Clerk) Date signed American LegalNet, Inc. www.FormsWorkFlow.com