PRE-TRIAL SCHOOL VIOLENCE PREVENTION PROGRAM APPLICATION, ORDER, DISPOSITION JD-CR-126 Rev. 9-09, C.G.S. § 54-56j 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. CSSD Case Number Docket Number Sex Date of Birth Telephone Number In Violation of General Statute Date of Offense TO: The Superior Court of the State of Connecticut Judicial District or G.A. Number Address of Court From (Name of defendant) Address of Defendant (Number, street, town and apartment number) Crime Charged Against the Defendant Involving Use or Threatened Use of Physical Violence Offense Location: 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 Date Signed PAGE 1 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com 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 cour