200-00011 Application for Home Detention Program (/201) Page 1 of 2 STATE OF VERMONT SUPERIOR COURT CRIMINAL DIVISION Unit Docket No. STATE OF VERMONT v. DOB APPLICATION FOR HOME DETENTION PROGRAM 1. Charges: Defendant is charged with the following offenses: Docket No. Offense 2. On , D efendant was ordered : Held pending payment of $ in cash on an Appearance Bond in the amount of$.Held pending payment of $ cash or Bail Bond with solvent securities. 3. Defendant has been detained at a correctional facility in the custody of the Commissioner of Corrections for lack of bail. Defendant is currently unable to post bail in the amount ordered by the court. 4. If Defendant was approved for the Home Detention Program, he /she agrees to reside at the following address: Street & Apt. #, if any Town/City State: Zip: 5. The owner (s) of the residence i s: 6. 7. The residents of this household are: 8. The 9. If other than D efendant, the owner of the residence approves of D efendant's residence at the home and will permit electronic surveillance equipment to be used at the residence. 10. Telephone coverage is required. Defendant must maintain a cell phone that is able to receive calls at the residence, or the residence must have a landline. American LegalNet, Inc. www.FormsWorkFlow.com 200-00011 Application for Home Detention Program (/201) Page 2 of 2 11. If approved for the program, Defendant requests that the court approve his /her absence from the home for the following purposes: Court appearances for these proceedings (no transport required) Employment at: Treatment A ppointments at: Medical A ppointments at: Attorney A ppointments at: Educational S ervices operated by the Department of Corrections. ** Other approved absences: ** All persons under the custody of the Commissioner of Corrections who are under 23 years of age and have not r eceived a high school diploma shall participate in the education program unless exempted by the Commission er per Title 28 VSA 120 12. If approved for the program, Defendant is willing to comply with his /her conditions of release, the standard conditions for the Home Detention Program and any other conditions the court may order. 13. If approved for the program, Defendant will be financially responsible for any lost or damaged electronic monitoring equipment tha t is assigned to him/her by the Department of Corrections. Dated Signature of Applicant cc : State's Attorney Defense Attorney Department of Corrections American LegalNet, Inc. www.FormsWorkFlow.com