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Pre Trial School Violence Prevention Program Application Order Disposition Form. This is a Connecticut form and can be use in Criminal Statewide.
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Tags: Pre Trial School Violence Prevention Program Application Order Disposition, JD-CR-126, Connecticut Statewide, Criminal
PRE-TRIAL SCHOOL VIOLENCE
PREVENTION PROGRAM
APPLICATION, ORDER, DISPOSITION
STATE OF CONNECTICUT
SUPERIOR COURT
www.jud.ct.gov
Instructions to Person Applying for Program
1. Send the original to the clerk of court.
2. Send a copy to the prosecuting attorney.
JD-CR-126 Rev. 9-09, C.G.S. § 54-56j
CSSD Case Number
TO: The Superior Court of the State of Connecticut
Docket Number
Judicial District or G.A. Number Address of Court
From (Name of defendant)
Sex
Date of Birth
Address of Defendant (Number, street, town and apartment number)
Telephone Number
Crime Charged Against the Defendant Involving Use or Threatened Use of Physical Violence
In Violation of General Statute
Offense Location:
Date of Offense
In or on property of elementary or secondary school
At school-sponsored activity as defined in Connecticut General Statutes §10-233a(b).
Name and Address of School or Description and Location of School-Sponsored Activity
I was a student of a public or private secondary school on the Date of Offense noted above and I am charged with the crime
listed above involving the use or threatened use of physical violence in or on the property of a public or private elementary
or secondary school or at a school-sponsored activity as defined in section 10-233a(h) of the general statutes. I am applying
for the Pre-Trial School Violence Prevention Program. I agree, if this application is granted:
1. To give the state more time to prosecute me for this charge (the tolling of the statute of limitations and to waive the right
to a speedy trial with respect to this violation.)
2. To go to a school violence prevention program consisting of at least 8 (eight) group counseling sessions
in anger management and nonviolent conflict resolution and to finish the program.
3. My parents or guardian will pay the cost of my being in the program unless my parent or guardian files with the court
an affidavit of inability to pay or indigency and the court decides that my parent or guardian do not have to pay.
I agree to let the Court Support Services Division get information about my criminal/motor vehicle or program participation
record in this and any other jurisdiction to see if I can be in the Pre-Trial School Violence Prevention Program.
If an affidavit of inability to pay or indigency is filed, the inability to pay or indigency must be confirmed by the Court Support
Services Division The court may decide my parent or guardian does not have to pay the fee if it finds that my parent or
guardian is unable to pay the fee or is indigent. ("X" one of the following)
My parent or guardian plans on claiming the inability to pay or indigency.
My parent or guardian plans on paying the program fee ($300, although the fee may be changed).
By signing this form, I ask that I be granted the Pre-Trial School Violence Prevention Program under section 54-56j of the
general statutes.
I have read this entire application and I understand it.
Signed (Defendant)
Date Signed
Consented and Agreed to By (Parent or Guardian)
Date Signed
Oath of Defendant
The defendant stated under penalties of false statement before me, duly designated by the clerk and authorized to
administer oaths, that (s)he has never had the Pre-Trial School Violence Prevention Program invoked in his/her behalf and
that (s)he has not been convicted of an offense involving the threatened use of physical violence in or on the real property
comprising a public or private elementary or secondary school or at a school-sponsored activity as defined in subsection (h)
of section 10-233a of the general statutes, that (s)he has not been convicted in any other state at any time of an offense the
essential elements of which are substantially the same as such an offense, and that to the best of his/her knowledge and
belief (s)he does not possess any firearms, dangerous weapons, controlled substances or other property or materials the
possession of which is prohibited by law or in violation of law.
Signed (Duly authorized person)
Print Name of Person Signing at Left
Date Signed
Oath of Parents or Guardian
The defendant's parents or guardian stated under penalties of false statement before me, duly designated by the clerk and
authorized to administer oaths, that to the best of said parents or guardian's knowledge and belief they do not possess any
firearms, dangerous weapons, controlled substances or other property or materials the possession of which is prohibited by
law or in violation of law.
Signed (Duly authorized person)
Print Name of Person Signing at Left
PAGE 1 OF 2
Date Signed
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First Order of Court
("X" all that apply) (If the court file is ordered unsealed consider ordering the defendant's date of birth redacted.)
The foregoing application is denied.
The case is continued until (date) _________________at (time) ___________a.m./p.m. to permit the defendant's parent or guardian
to file an affidavit of indigency and for the Court Support Services Division to seek to confirm such indigency.
The defendant stated under penalties of perjury that (s)he has never had the Pre-trial School Violence Prevention Program
invoked in his/her behalf and that (s)he has not been convicted of an offense involving the threatened use of physical violence in
or on the real property comprising a public or private elementary or secondary school or at a school-sponsored activity as defined
in subsection (h) of section 10-233a of the general statutes, that (s)he has not been convicted in any other state at any time of an
offense the essential elements of which are substantially the same as such an offense, and the defendant and the defendant's
parents or guardian stated under oath that to the best of their knowledge and belief, they do not possess any firearms, dangerous
weapons, controlled substances or other property of materials the possession of which is prohibited by law or in violation of law.
The court orders the court file sealed as to the public, and refers the defendant to the Court Support Services Division for
assessment and confirmation of the eligibility of the defendant. If the Court Support Services Division confirms that the defendant
is eligible, it shall evaluate and place the defendant in an appropriate school violence prevention program for one year.
The court denies the application for waiver of fees and the defendant's parents or guardian is ordered to pay the cost of participation
in such program to the program provider.
The court waives the fee having found that the defendant's parents or guardian is indigent or unable to pay.
Case Continued To (Date and time)
Signed (Judge, assistant clerk)
Date Signed
Court Support Services Division Assessment and Confirmation
Prior Physical Violence Conviction - School Related
Yes
Yes
No
No
No (Affidavit attached)
Yes
No
Signed (CSSD staff)
Assessment
Able to Pay Program Fee
Yes
Prior Program Participation
Out-of-State Conviction
Eligible
Ineligible
Second Order of Court (If assessed ineligible or claim of indigency)
("X" ALL THAT APPLY)
The court, having determined that the defendant is ineligible, denies the foregoing application and the court file is ordered
to be unsealed.
The foregoing application is granted and the defendant is referred to the Court Support Services Division for evaluation and
placement in an appropriate school violence prevention program for one year.
The court denies the application for waiver of fees and the defendant's parents or guardian is ordered to pay
to the program provider the cost of participation on such program.
The court waives the fee having found that the defendant's parents or guardian is indigent or unable to pay.
Case Continued To (Date and time)
Signed (Judge, assistant clerk)
Date Signed
PAGE 2 OF 2
JD-CR-126 (Back) Rev. 9-09
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