PRETRIAL ALCOHOL EDUCATION PROGRAM APPLICATION JD-CR-44 Rev. 10-16 C.G.S. � 54-56g; P.A. 16-126 �� 4,5 STATE OF CONNECTICUT SUPERIOR COURT JUDICIAL BRANCH www.jud.ct.gov Instructions To Person Filling Out This Application 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. � 54-56g. 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. ADA Notice TO: The Superior Court of the State of Connecticut GA/JD number Address of court Docket number Address of defendant (Number, street, apartment number, town, and zip code) Telephone number of defendant Operator's license number Issuing state Name of defendant Alias/Maiden name of defendant Offense(s) charged I am charged with a violation of section 14-227a, 14-227g, 15-133, or 15-140n of the Connecticut General Statutes or a violation of Public Act 16-126 section 1 or section 2(a)(1) or (2), and I am applying for the Pretrial Alcohol Education Program. If my application is granted: 1. I agree to give the State more time to prosecute me (the tolling of any statute of limitations for this offense(s) and to waive my right to a speedy trial) for the offense(s) listed above if I do not complete the program. 2. I understand that the Department of Mental Health and Addiction Services (DMHAS) and the Court Support Services Division (CSSD) will make a recommendation to the court about whether I should take part in 10 or 15 counseling sessions in an alcohol intervention program or at least 12 sessions in a substance abuse treatment program. I also agree to begin the alcohol intervention or substance abuse treatment program that the court orders me into within 90 days unless the court gives me more time, and I understand that I can wait to begin my program until after the suspension of my license is over. I also agree to finish the program that the court orders me into, and after I finish my program, if CSSD thinks I need more treatment, I agree to accept any additional treatment in a treatment program recommended by a DMHAS contractor, or to be placed in a state-licensed treatment program that meets standards set by DMHAS. 3. I agree to take part in at least one (1) Victim Impact Panel if the court orders me to. 4. If I decide to enter the program ordered by the court after the suspension of my license is over, I agree to tell CSSD the date that my license was suspended and how long my license was suspended for. 5. I agree to pay the court a nonrefundable program fee of $350 if I am ordered into the 10 session alcohol intervention program, or $500 if I am ordered into the 15 session alcohol intervention program (these fees may be changed by the legislature), or to pay the costs of taking part in a substance abuse treatment program if I am ordered into a treatment program, except that, if I cannot pay or if I am indigent, I will file with the court an affidavit saying I cannot pay or that I am indigent, and the court may decide that I do not have to pay some or all of the program fee or costs of the treatment program if it finds that I am indigent or unable to pay. I give my permission to CSSD to get information about any criminal or motor vehicle program I may have been in in this state or in any other jurisdiction so that CSSD can decide if I can be allowed into the program. If I am telling the court that I cannot pay or that I am indigent by filing an affidavit of my inability to pay or of my indigency, I give my permission to CSSD to get information to decide if I cannot pay or if I am indigent. ("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. By signing this form, I am saying that I understand all of the information above, and I request that I be allowed into the Pretrial Alcohol Education Program under section 54-56g of the Connecticut General Statutes. I have read this entire application, and I understand it. Signed (Defendant) Date Signed Consented to By (Parent or guardian) Notice Unless good cause is shown, a person is not eligible for the Pretrial Alcohol Education Program if the alleged violation of section 14-227a, 14-227g, or 15-133(d) of the Connecticut General Statutes, or of Public Act 16-126 section 1 or section 2(a)(1) or (2) caused the serious physical injury, as defined in section 53a-3, of another person. (Page 1 of 2) American LegalNet, Inc. www.FormsWorkFlow.com Oath The applicant stated under penalties of perjury before me, duly designated by the clerk and authorized to administer oaths, that (1) if (s)he is charged with a violation of section 14-227a, 14-227g, 15-133(d), or 15-140n of the Connecticut General Statutes or a violation of Public Act 16-126 section 1 or section 2(a)(1) or (2), (s)he has not had the Pretrial Alcohol Education Program invoked in his/her behalf within the preceding ten (10) years for a violation of section 14-227a, 14-227g, 15-133(d), or 15-140n of the Connecticut General Statutes or a violation of Public Act 16-126 section 1 or section 2(a)(1) or (2); (2) that (s)he has never been convicted of a violation of: a. Section 14-227g, 53a-56b, or 53a-60d of the Connecticut General Statutes; b. Public Act 16-126 section 1 or section 2(a)(1) or (2); c. Section 14-227a(a) of the Connecticut General Statutes before, on or after October 1, 1981; or d. Section 14-227a(a)(1) or (2) of the Connecticut General Statutes on or after October 1, 1985; (3) that (s)he has not been convicted of a violation of section 15-132a, 15-133(d), 15-140l, or 15-140n of the Connecticut General Statutes; (4) that (s)he has not been convicted in any other state, at any time, of an offense that has essential elements that are substantially the same as sections 14-227a(a)(1) or (2), 15-132a, 15-133(d), 15-140l, 15-140n, 53a-56b, or 53a-60d of the Connecticut General Statutes or a violation of Public Act 16-126 section 1 or section 2(a)(1) or (2); (5) if (s)he is charged with a violation of section 14-227a of the Connecticut General Statutes or a violation of Public Act 16-126 section 1 or section 2(a)(1) or (2),