FAMILY VIOLENCE EDUCATION PROGRAM APPLICATION, ORDERS AND DISPOSITION JD-FM-97 Rev. 3-16 C.G.S. §§ 46b-38c(h) and (i), 46b-38a, 53a-3 TO: The Superior Court of the State of Connecticut Instructions To Person Applying for Program 1. Fill out the Application section and make 2 copies. 2. Send the Original to the Clerk of Court and one copy to the Prosecuting Attorney. 3. A $100 application fee, or an application for waiver of the fee (form JD-AP-48), must be filed with this application. 4. Keep a copy for your records. www.jud.ct.gov Application Name and address of defendant (Number, street, town, and zip code) Name and address of court Crime(s) charged (Name and statute number) 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 CR- I am applying for the Family Violence Education Program. 1. I have not already been convicted of a "family violence crime," as defined by the General Statutes, which happened on or after October 1, 1986. (See section 46b-38a of the Connecticut General Statutes for the definition of "family violence crime.") 2. I have not had another case assigned to the Family Violence Education Program. 3. I have not used accelerated rehabilitation under section 54-56e of the Connecticut General Statutes for a "family violence crime" that happened on or after October 1, 1986. 4. I am not charged with a class A, class B, or class C felony, or an unclassified felony for which the punishment could be a term of imprisonment of more than ten (10) years. 5. ("X" if this applies to you) I am charged with a class D felony, an unclassified offense for which a punishment could be a term of imprisonment of more than five (5) years, or an offense that involved the infliction of serious physical injury. (See section 53a-3 for the definition of "serious physical injury.") If this box is checked, you must explain in writing why you think there is good cause to grant you this program. You must attach your explanation to this application. If my application is granted, I agree to: 1. Giving the state more time to prosecute me (the tolling of any statute of limitations and the waiver of the right to a speedy trial) for the crime(s) with which I am charged; and 2. Pay to the court the $300 fee for the Family Violence Education Program, except that if I cannot pay this fee, I will file with the court an affidavit of my inability to pay or indigency. If I file an affidavit of my inability to pay or indigency, the court may waive the program fee if it finds that I am unable to pay or that I am indigent. ("X" one) I plan on claiming that I am unable to pay or that I am indigent. I plan to pay the program fee. Dismissal Application I also ask that, if this application for the Family Violence Education Program is granted, and if I successfully finish the program and follow all of the conditions set by the court, the court dismiss the charges against me. I ask that I be allowed into the Family Violence Education Program under section 46b-38c(h) of the Connecticut General Statutes. I have read the information above, or I have had the information above read to me, and I understand it. I agree to the statements above and affirm that they are true under penalty of perjury. Signed (Defendant) Date Signed If Minor, Consented to By (Parent or Guardian) Date Signed Notice Unless good cause is shown, a defendant is not eligible to participate in the Family Violence Education Program if charged with a Class D felony, an unclassified offense carrying a term of imprisonment of more than five (5) years, or an offense that involved infliction of serious physical injury. First Order of Court The application is denied. The defendant is referred to the Family Violence Intervention Unit, and this case is continued to the date listed below and pending the submission of the report of the Family Violence Intervention Unit to the court. Court Hearing Date and Time Signed (Judge/Assistant Clerk) Date Signed For Court Use Only Date Victim Notified (Use form JD-FM-96) Date of Family Violence Intervention Unit Report Date Filed Affidavit of inability to pay or indigency To Yes No Continuances (If Any) To (continued...) Family Violence Education Program - Application, Orders, and Disposition American LegalNet, Inc. www.FormsWorkFlow.com Oath (Optional with the Court) The defendant appeared before the undersigned individual, designated by the clerk and duly authorized to administer oaths, and confirmed, under penalties of perjury, the statements made in the application and any statements attached to the application containing the reasons why the defendant believes good cause exists to invoke the program even though the defendant is charged with a class D felony, an unclassified offense carrying a term of imprisonment of more than five years, or an offense that involved the infliction of serious physical injury. Signed (Clerk's Designate, Duly Authorized) Title Date Second Order of Court THE COURT, having considered the application, the report of the Family Violence Intervention Unit, and the statement(s), if any, of the victim(s) finds: That the defendant is eligible for the Family Violence Education Program. That the defendant is charged with a class D felony, an unclassified offense carrying a term of imprisonment of more than five years, or and offense that involved the infliction of serious physical injury, and that good cause exists to invoke this program on behalf of such defendant. That the defendant is NOT eligible for the Family Violence Education Program. The court orders: The application is DENIED. The application is GRANTED, and the defendant is released to the custody of the Family Violence Intervention Unit for the period indicated below. The following conditions are also imposed: The court denies the application for waiver of fee. The defendant is ordered to pay the clerk the applicable program fee. The court waives the fee having found that the defendant is indigent or unable to pay. Case Continued To (Date and Time) Signed (Judge/Assistant Clerk) Date FEE PAID Clerk's Initials Date Disposition (Complete One Side Only) Program Successfully Completed and Charges Dismissed Signed (Judge/Assistant Clerk) JD-FM-97 (Back) Rev. 3-16 Date Program Not Successfully Completed Conditions Not Complied With S