PRETRIAL ALCOHOL EDUCATION PROGRAM REQUEST FOR REINSTATEMENT JD-CR-44R Rev. 10-16 C.G.S. § 54-56g 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 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 ADA Notice 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 Operator's license number CMIS case number Issuing state I applied for the Pretrial Alcohol Education 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 amenable to treatment. I now request reinstatement into the Pretrial Alcohol Education Program. If my request is granted, I understand that I must pay a nonrefundable program fee of $175 if the court orders me to take part in a 10-session intervention program, or $250 if the court orders me to take part in a 15-session intervention program, which will not be waived unless the court finds good cause (a reason why I should not have to pay). I understand that, if the court orders me to take part in a substance abuse treatment program, I must also pay the costs of reinstatement into the program, if there are any. Signed (Defendant) Print Name Date 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. 10 sessions recommended 15 sessions recommended Substance abuse treatment program recommended Print Name Next court date Date Signed (Bail Services staff) Court Order ("X" all that apply) (If the application is denied and the file ordered unsealed, consider ordering the defendant'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 for placement in an appropriate alcohol intervention program for one year or to be placed in a state-licensed substance abuse treatment program. The defendant is ordered to enter the program without delay. The defendant shall participate in one victim impact panel. The program fee is: $175 (10 sessions) $250 (15 sessions) The defendant is ordered to pay the clerk the nonrefundable program fee immediately. The program fee is waived for good cause shown. The substance abuse treatment program costs: Shall be paid by the defendant. Are waived for good cause shown. Case continued to (Date and time) Signed (Judge, Assistant Clerk) Date signed American LegalNet, Inc. www.FormsWorkFlow.com