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Application For Erie County Treatment Program - Pennsylvania
| Application For Erie County Treatment Program Form. This is a Pennsylvania form and can be used in District Attorney Erie Local County . |
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COMMONWEALTH OF PENNSYLVANIA v. _____________________________________ : : : : : : IN THE COURT OF COMMON PLEAS OF ERIE COUNTY, PENNSYLVANIA CRIMINAL DIVISION NO.:________________ OF 20_____ OTN:___________________________ APPLICATION FOR ERIE COUNTY TREATMENT COURT Application is hereby made for disposition of this case under the Erie County Treatment Program. To assist the 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 N.A. 1. 2. Full Name of the defendant: _____________________________________________________________ Maiden Name of defendant; or other last names previously used: ________________________________ ____________________________________________________________________________________ 3. 4. 5. Date of Birth: ___________________ Social Security Number: _________________________________ Driver License Number: _____________________________ State Issued: ________________________ Present Address:_______________________________________________________________________ City: ________________________ State: ____________ Zip Code: _______________________ (Cell) ( ) Phone(Home) ( ) 6. Present Employment: Work Phone ( ) 7. Next of Kin or Emergency Contact: Name: Phone ( ) 8. 9. Education-Schools and Highest Year attained: _______________________________________________ Do you have any other pending criminal charge(s)? If so, explain giving date, place, charges and disposition: ____________________________________________________________________________________ ____________________________________________________________________________________ 10. Do you have a history of drug/alcohol abuse and/or serious mental illness treatment? If so, give details. (Use reverse side if needed): ____________________________________________________________________ ____________________________________________________________________________________ 11. Explanation of your present case, including all details (use reverse side if needed): ____________________ ____________________________________________________________________________________ ____________________________________________________________________________________ PLEASE SUBMIT COPY OF CRIMINAL COMPLAINT WITH THIS APPLICATION. 1 f 2 American LegalNet, Inc. www.FormsWorkFlow.com 12. By applying for ECT Program and by signing this application I acknowledge, certify, and understand each of the following rights and responsibilities: A. 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. 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. I hereby waive (give up) all of my constitutional rights to a speedy trial, as set forth, from the date I sign this Application until I either complete the ECT Program or am revoked from it, should I violate the conditions the 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 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 and to allow the District Attorney as much time as he needs to evaluate my suitability for the ECT Program. I have not been made any promises, nor have I been forced or coerced to sign this waiver. B. I understand I have the right to be represented by an attorney on my charge(s) and also in connection with my ECT Application. If I cannot afford counsel, the Court will provide me free counsel through the Erie County Public Defender's Office. C. It is my responsibility to notify the District Attorney's Office, in writing, of my arrest and/or conviction for any offense occurring after this Application is made and before it is rejected or I am accepted into the Program by the Court. Failure to comply with this requirement is grounds for refusal of the Application and/or may be treated as a false statement subjecting me to prosecution and/or for removal from the Program. D. I acknowledge that I have completed (or will complete prior to my ECT hearing) all processing (e.g. Fingerprinting, etc.) required of me. I understand that failure to do so may delay my acceptance into the program. E. The information I have provided above is true and correct. I understand if I have provided false information 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. DATE:_________________________ DEFENDANT:______________________________________________ DATE:_________________________ ATTY. FOR DEFENDANT:___________________________________ Please Print Revised 2/9/11 2 f 2 American LegalNet, Inc. www.FormsWorkFlow.com
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