Form JD-CR-126 Pretrial School Violence Prevention Program Application, Order, Disposition - Connecticut

Form JD-CR-126 or the "Pretrial School Violence Prevention Program Application, Order, Disposition" is a form issued by the Connecticut Superior Court.

Download a PDF version of the Form JD-CR-126 down below or find it on the Connecticut Superior Court Forms website.

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PRETRIAL SCHOOL VIOLENCE
STATE OF CONNECTICUT
PREVENTION PROGRAM APPLICATION,
SUPERIOR COURT
ORDER, DISPOSITION
www.jud.ct.gov
Instructions to Person Applying for Program
JD-CR-126 Rev. 10-17
1. Send the original to the clerk of court.
C.G.S. § 54-56j; P.A. 17-99 § 20
2. Send a copy to the prosecuting attorney.
To: The Superior Court of the State of Connecticut
Address of court
Docket number
GA/JD
number
Name of defendant
Address of defendant (Number, street, apartment number, town, and zip code)
Telephone number of defendant
CMIS case number
Alias/Maiden name of defendant
Offense(s) charged (List offenses involving use or threatened use of physical violence)
Date of offense
In or on property of elementary or secondary school
Offense Location:
At school-sponsored activity as defined in section10-233a (b) of the Connecticut General Statutes.
Name and Address of School or Description and Location of School-Sponsored Activity
I was a student of a public or private secondary school on the Date of Offense noted above and I am charged with the crime
listed above involving the use or threatened use of physical violence in or on the property of a public or private elementary or
secondary school or at a school-sponsored activity as defined in section 10-233a(h) of the Connecticut General Statutes. I am
applying for the Pretrial School Violence Prevention Program. I agree, if this application is granted:
1. To give the state more time to prosecute me for this charge (the tolling of the statute of limitations and to waive the
right to a speedy trial with respect to the offense(s) listed above.)
2. To go to a school violence prevention program consisting of group counseling sessions in anger management and
nonviolent conflict resolution and to finish the program and to complete the assigned program.
I agree to let the Court Support Services Division (CSSD) get information about my criminal/motor vehicle or program
participation record in this and any other jurisdiction to see if I can be in the Pretrial School Violence Prevention Program.
By signing this form, I ask that I be allowed into the Pretrial School Violence Prevention Program under section 54-56j of the
Connecticut General Statutes.
I have read this entire application and I understand it.
Date signed
Date signed
Signed (Defendant)
Consented and agreed to by (Parent or Guardian)
Oath of Defendant
The defendant stated under penalties of false statement before me, duly designated by the clerk and authorized to administer
oaths, that (s)he has never had the Pretrial School Violence Prevention Program invoked in his/her behalf and that (s)he has
not been convicted of an offense involving the threatened use of physical violence in or on the real property comprising a
public or private elementary or secondary school or at a school-sponsored activity as defined in subsection (h) of section
10-233a of the Connecticut General Statutes, that (s)he has not been convicted in any other state at any time of an offense
the essential elements of which are substantially the same as such an offense, and that to the best of his/her knowledge and
belief (s)he does not possess any firearms, dangerous weapons, controlled substances, or other property or materials the
possession of which is prohibited by law or in violation of the law.
Print name
Date signed
Signed (Duly authorized person)
Oath of Parents or Guardian
The defendant's parents or guardian stated under penalties of false statement before me, duly designated by the clerk and
authorized to administer oaths, that to the best of said parents or guardian's knowledge and belief they do not possess any
firearms, dangerous weapons, controlled substances, or other property or materials the possession of which is prohibited by
law or in violation of the law.
Signed (Duly authorized person)
Print name
Date signed
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.
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PRETRIAL SCHOOL VIOLENCE
STATE OF CONNECTICUT
PREVENTION PROGRAM APPLICATION,
SUPERIOR COURT
ORDER, DISPOSITION
www.jud.ct.gov
Instructions to Person Applying for Program
JD-CR-126 Rev. 10-17
1. Send the original to the clerk of court.
C.G.S. § 54-56j; P.A. 17-99 § 20
2. Send a copy to the prosecuting attorney.
To: The Superior Court of the State of Connecticut
Address of court
Docket number
GA/JD
number
Name of defendant
Address of defendant (Number, street, apartment number, town, and zip code)
Telephone number of defendant
CMIS case number
Alias/Maiden name of defendant
Offense(s) charged (List offenses involving use or threatened use of physical violence)
Date of offense
In or on property of elementary or secondary school
Offense Location:
At school-sponsored activity as defined in section10-233a (b) of the Connecticut General Statutes.
Name and Address of School or Description and Location of School-Sponsored Activity
I was a student of a public or private secondary school on the Date of Offense noted above and I am charged with the crime
listed above involving the use or threatened use of physical violence in or on the property of a public or private elementary or
secondary school or at a school-sponsored activity as defined in section 10-233a(h) of the Connecticut General Statutes. I am
applying for the Pretrial School Violence Prevention Program. I agree, if this application is granted:
1. To give the state more time to prosecute me for this charge (the tolling of the statute of limitations and to waive the
right to a speedy trial with respect to the offense(s) listed above.)
2. To go to a school violence prevention program consisting of group counseling sessions in anger management and
nonviolent conflict resolution and to finish the program and to complete the assigned program.
I agree to let the Court Support Services Division (CSSD) get information about my criminal/motor vehicle or program
participation record in this and any other jurisdiction to see if I can be in the Pretrial School Violence Prevention Program.
By signing this form, I ask that I be allowed into the Pretrial School Violence Prevention Program under section 54-56j of the
Connecticut General Statutes.
I have read this entire application and I understand it.
Date signed
Date signed
Signed (Defendant)
Consented and agreed to by (Parent or Guardian)
Oath of Defendant
The defendant stated under penalties of false statement before me, duly designated by the clerk and authorized to administer
oaths, that (s)he has never had the Pretrial School Violence Prevention Program invoked in his/her behalf and that (s)he has
not been convicted of an offense involving the threatened use of physical violence in or on the real property comprising a
public or private elementary or secondary school or at a school-sponsored activity as defined in subsection (h) of section
10-233a of the Connecticut General Statutes, that (s)he has not been convicted in any other state at any time of an offense
the essential elements of which are substantially the same as such an offense, and that to the best of his/her knowledge and
belief (s)he does not possess any firearms, dangerous weapons, controlled substances, or other property or materials the
possession of which is prohibited by law or in violation of the law.
Print name
Date signed
Signed (Duly authorized person)
Oath of Parents or Guardian
The defendant's parents or guardian stated under penalties of false statement before me, duly designated by the clerk and
authorized to administer oaths, that to the best of said parents or guardian's knowledge and belief they do not possess any
firearms, dangerous weapons, controlled substances, or other property or materials the possession of which is prohibited by
law or in violation of the law.
Signed (Duly authorized person)
Print name
Date signed
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.
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First Order of Court
("X" all that apply) (If the court file is ordered unsealed consider ordering the defendant's telephone number redacted.)
The application is denied.
The defendant's oath, and the oath of the defendant's parents or guardian under section 54-56j(b) were taken:
In open court
Outside of court by a person designated by the clerk and duly authorized to administer oaths
The application is granted. The court orders the court file sealed as to the public, and refers the defendant to CSSD
for assessment and confirmation of the eligibility of the defendant. If CSSD confirms that the defendant is eligible, it
shall evaluate and place the defendant in an appropriate school violence prevention program for one year.
Case continued to (Date and time)
Signed (Judge, Assistant Clerk)
Date signed
Court Support Services Division Assessment and Confirmation
Prior physical violence conviction - school related:
Out-of-State conviction:
Prior program participation:
Yes
No
Yes
No
Yes
No
Assessment:
Signed (CSSD staff)
Eligible
Ineligible
Second Order of Court (If assessed ineligible)
("X" all that apply)
The court, having determined that the defendant is ineligible, denies this application. Further, the court orders that
the court file be unsealed, a plea of not guilty entered, and this case to be placed on the trial list immediately.
This application is granted, and the defendant is referred to CSSD for evaluation and placement in an appropriate
school violence prevention program for one year.
Case continued to (Date and time)
Signed (Judge, Assistant Clerk)
Date signed
JD-CR-126 (Back) Rev. 10-17
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Download Form JD-CR-126 Pretrial School Violence Prevention Program Application, Order, Disposition - Connecticut

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