SUSPENSION OF SENTENCE/ ORDER OF COMMUNITY SERVICE APPLICATION AND ORDER JD-CR-80 Rev. 10-13 C.G.S. §§ 21a-279, 53a-39c, P.A. 13-159, Sec. 2 Instructions to Defendant 1. Forward first three copies to clerk of court. 2. Send last copy to the state's attorney. Instructions to Clerk 1. Unless denied, upon the first order of the court, forward a copy to Office of Adult Probation. 2. Unless denied, upon the second order of the court, forward a copy to Office of Adult Probation. 3. Retain original in court file. ADA NOTICE 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. To: The Superior Court of the State of Connecticut From (Name of defendant) Address of defendant Judicial district or Geographical area Address of court In violation of General Statute 21a-267 21a-279 Application I, the undersigned Defendant, hereby make application and say: 1. I have pled guilty without trial to a first violation of the sections of Connecticut General Statutes specified above. 2. I have not previously been convicted of a violation of Connecticut General Statutes sections 21a-277 or 21a-278. 3. I have not previously been placed in the community service labor program. 4. I agree, if this application is granted, to pay the court forthwith a participation fee of $205, unless such fee is waived. I understand that the court may waive the participation fee if (1) I file with the court an affidavit of indigency or inability to pay, (2) such indigency is confirmed by the Court Support Services Division, and (3) the court enters a finding of indigency. ("X" one of the following): I intend to claim indigency or inability to pay. I intend to pay the $205 participation fee. WHEREFORE, the undersigned requests that any sentence of imprisonment be suspended and that the court order participation in the community service labor program as a condition of probation or conditional discharge. I have read the above and understand it. I agree with the foregoing statements. Consented to by (Parent or Guardian) Signed (Defendant) Date signed Signed (Attorney for Defendant) Date signed 1st Order The foregoing Application is denied. The foregoing Application is continued to the following Court Hearing Date so that the Defendant's prior criminal record and record of prior participation in the community service labor program may be verified. Court hearing date and time Signed (Judge or Assistant Clerk) Date signed Defendant is ineligible for the following reasons: Prior CSLP participation Prior conviction of C.G.S. § 21a-277 or § 21a-278 Affidavit of indigency or inability to pay -- The Defendant's affidavit of indigency or inability to pay was: Confirmed Not Confirmed The foregoing Application is denied. Having found that the defendant was charged with a first violation of Connecticut General Statutes section 21a-267 or 21a-279 and pled guilty without a trial to said violation, a term of imprisonment is part of the stated plea agreement, the Defendant has not previously been convicted of a violation of Connecticut General Statutes sections 21a-277 or 21a-278, and the Defendant has not been placed in the community service labor program before, the application is granted; the sentence is suspended subject to an order of: For Court Use Only Defendant is eligible Report (if applicable) 2nd Order PROBATION for a period of __________________________ CONDITIONAL DISCHARGE for a period of _______________________ a special condition of which is that the Defendant participate in a community service labor program for the period specified below: PERIOD OF PARTICIPATION IS 30 DAYS and payment of the participation fee unless waived below. The court, having found that the defendant is indigent or has an inability to pay, waives the payment of the $205 participation fee. Other (specify): ________________________________________ Signed (Assistant clerk) Date signed Docket number (For court use only) By the court (Name of judge) American LegalNet, Inc. www.FormsWorkFlow.com