COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. COMMONWEALTH OF PENNSYLVANIA : IN THE COURT OF No. : Index COMMON PLEAS V. _____________________________________ -against- : OF ERIE COUNTY, PENNSYLVANIA : : CRIMINAL DIVISION No. Calendar : : : NO.:________________ OF 20_____ JUDICIAL SUBPOENA Plaintiff(s) : OTN:___________________________ : APPLICATION FOR DISPOSITION UNDER THE : ERIE COUNTY TREATMENT PROGRAM : Application is hereby made for disposition of this case under the Erie County Treatment Program. To assist the Defendant(s) : District Attorney’s .Office .in. evaluating. the. suitability .of. this . case. for .the Erie County Treatment Program, the ........ ..... . ......... .. ......... . ... ... ... following information is provided: INSTRUCTIONS: Answer all questions that apply. If a question does not apply, answer it with the initials THE PEOPLE OF THE STATE OF NEW YORK “N.A.” 1. TO Full Name of the defendant: _____________________________________________________________ 2. Maiden Name of defendant; or other last names previously used: ________________________________ GREETINGS: ____________________________________________________________________________________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before 3. Date of Birth: ___________________ Social Security Number: _________________________________ the Honorable at the Court 4. Driver License Number:the in room , on _____________________________ State Issued: ________________________ day of , 20 , at o'clock in the noon, and at any recessed located at County of or adjourned date, to testify and give evidence as a witness in this action on the part of the 5. Present Address: _______________________________________________________________________ City: ________________________ State: ____________ Zip Code: _______________________ to Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a 6. Present Employment: __________________________________________________________________ result of your failure to comply. 7. Education-Schools and Highest Year attained: _______________________________________________ Witness, Honorable , one of the Justices of the Court in County, day of , 20 Do you have any other pending criminal charge(s)? If so, explain giving date, place, charges and disposition: ____________________________________________________________________________________ (Attorney must sign above and type name below) ____________________________________________________________________________________ 8. Attorney(s) for Explanation of your present case, including all details (use reverse side if needed): ____________________ ____________________________________________________________________________________ Office and P.O. Address ____________________________________________________________________________________ Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Page 1 of 1 American LegalNet, Inc. www.USCourtForms.com , 9. COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. Do you have a history of drug/alcohol abuse and/or serious mental illness treatment? If so, give details. : Index No. : (Use reverse if needed) ________________________________________________________________ Calendar No. 10. : __________________________________________________________________________________ JUDICIAL SUBPOENA Plaintiff(s) By applying for ECT Program and by signing this application I acknowledge, certify, and understand each -against: of the following rights and responsibilities: : 1. I have been advised and I understand that I have a constitutional right to a speedy trial; that pursuant to Pa.R.Crim P. 600 formerly Pa.R.Crim. P. 1100, the Commonwealth must bring my case to trial within 365 days : from the filing of the Criminal Complaint, I understand I can ask the Court to dismiss all charges against me. Defendant(s) Furthermore, I understand that in the event I am incarcerated on these charges, the Commonwealth must bring my : ...................................................... case to trial within 180 days from the date of the filing of the Criminal Complaint, if the Commonwealth fails to do so, I can ask the Court for nominal bail. THE waive (give up) STATE constitutional rights to a speedy trial, as set forth, from the date I sign this I herebyPEOPLE OF THEall of myOF NEW YORK Application until I either complete the ECT Program or am revoked from it, should I violate the conditions the TO Court imposes on me. In the event my Application for ECT is denied, I waive (give up) all of my constitutional rights to a speedy trial as set forth, from the date I sign this Application until the last scheduled day of the term of Criminal Court next following the date of my rejection. I have been advised and I understand that by signing this waiver I am waiving (giving up) any and all rights I may have to be tried within 180 (if in jail) or 365 days GREETINGS: following the filing of the Criminal Complaint against me. I am signing the waiver because I understand it is to my benefit to do so andWEallow the District Attorneybusiness and excuses needs laid aside, you and each of you attend before to COMMAND YOU, that all as much time as he being to evaluate my suitability for the ECT Program. the Honorable made any promises, nor have I at the forced or coerced to sign this waiver. I have not been been , Court County of located at 2. I understand I have the right to be represented by an20 in room , on the day of , attorney on my charge(s) the also in connection with , at o'clock in and noon, and at any recessed my ECT Application. date,cannot afford give evidence Court will provideaction on counsel of the the Erie County or adjourned If I to testify and counsel, the as a witness in this me free the part through Public Defender’s Office. 3. It is my responsibility to notify the District Attorney’s Office, in writing, of my arrest and/or conviction for Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to any offense occurring whose behalf this subpoena wasand before a maximum penalty ofaccepted into the Program by as a the party on after this Application is made issued for it is rejected or I am $50 and all damages sustained the Court. result of your failurewith this requirement is grounds for refusal of the Application and/or may be treated Failure to comply to comply. as a false statement subjecting me to prosecution and/or for removal from the Program. Witness, Honorable , one of the Justices of the 4. I acknowledge that I have completed (or will complete prior to my ECT hearing) all processing (e.g. Court in County, day of , 20 Fingerprinting, etc.) required of me. I understand that failure to do so may delay my acceptance into the program. 5. The information I have provided above is true and correct. I understand if I have provided false information (Attorney must sign above and type name below) on this Application, that reason alone is sufficient to refuse this Application. In addition, I understand that by providing false information I can be prosecuted for offenses including, but not limiting to, perjury, false swearing and/or unsworn falsification to authorities. Attorney(s) for DATE:_________________________ DEFENDANT:______________________________________________ Office and P.O. Address DATE:_________________________ ATTY. FOR DEFENDANT:___________________________________ Please Print Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Page 2 of 2 American LegalNet, Inc. www.USCourtForms.com