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Family Violence Education Program Application

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FAMILY VIOLENCE EDUCATION PROGRAM
APPLICATION, ORDERS AND DISPOSITION

JD-FM-97 Rev. 8-17

C.G.S. §§ 46b-38c(h) and (i), 46b-38a, 53a-3

TO: The Superior Court of the State of Connecticut

Application

Name and address of defendant (Number, street, town, and zip code)

Name and address of court

Crime(s) charged (Name and statute number)

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.
State of Connecticut Judicial Branch Seal

STATE OF CONNECTICUT

TRUTH-EQUITY-JUSTICE

JUDICIAL BRANCH

www.jud.ct.gov

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

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

Affidavit of inability to pay or indigency

Yes No

Date Filed

Continuances (If Any)

To

To

(continued...)

Family Violence Education Program - Application, Orders, and Disposition

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.

FEE PAID

Clerk's Initials

Date

Case Continued To (Date and Time)

Signed (Judge/Assistant Clerk)

Date

Disposition (Complete One Side Only)

Program Successfully Completed and Charges Dismissed

Signed (Judge/Assistant Clerk)

Date

Program Not Successfully Completed

Conditions Not Complied With

Signed (Judge/Assistant Clerk)

Date

JD-FM-97 (Back) Rev. 8-17

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What the Family Violence Education Program Application Is

The Family Violence Education Program Application is a standardized form used to enroll individuals in a court-ordered or agency-referred educational program addressing family or domestic violence. It collects applicant identification, program referral or order details, contact and eligibility information, and any special accommodations. The form documents consent to attend, acknowledges program rules, and creates an administrative record used by courts, probation offices, or program providers to track enrollment, attendance, completion, and compliance with referral or sentencing conditions.

Why a Properly Completed Application Matters

Completing the Family Violence Education Program Application accurately protects participant rights, ensures the program meets court or agency requirements, and prevents administrative delays. The application creates an auditable record for compliance, supports accurate reporting of attendance and outcomes, and helps providers assess participant suitability and support needs.

Why a Properly Completed Application Matters

Who Typically Completes and Processes This Application

Multiple parties interact with this application depending on context: applicants, program administrators, court clerks, probation officers, and referring counsel or victim advocates.

  • Applicant — completes personal, contact, and eligibility fields; provides signatures and consents.
  • Court/Probation Officer — verifies referral details, attaches court order or diversion paperwork, and confirms eligibility.
  • Program Administrator — reviews application, schedules intake, records attendance and completion status.

Clear role separation reduces processing errors and ensures the application links to the correct case or referral number for reporting and enforcement.

Stepwise Process to Complete the Application

Follow these sequential steps to fill out and submit the Family Violence Education Program Application correctly.

  • 01
    Gather Documents: Collect court order, ID, and referral details.
  • 02
    Complete Fields: Enter personal, referral, and contact information fully.
  • 03
    Attach Proof: Upload or attach the court order and any supporting documents.
  • 04
    Sign and Submit: Sign electronically or in-person and send to the program or court contact.

Typical Submission and Intake Flow

This overview describes the common routing from applicant to program provider and back to the referring authority.

  • Applicant Submission: Applicant completes and signs the application and attaches referral.
  • Program Intake: Administrator reviews eligibility and schedules orientation.
  • Attendance Tracking: Provider records attendance and progress in program records.
  • Reporting Back: Provider sends completion or noncompliance reports to the referring agency.

Configuring a Digital Workflow for Online Completion

Set up fields and routing to match court or agency requirements and to capture an audit trail for compliance.

Field Configuration
Applicant Info Required text fields, validation for DOB and phone
Referral Upload Mandatory PDF upload with filename convention
Signature eSignature field with consent checkbox
Routing Auto-send to program admin then to referring officer

Technical Considerations for eSubmission

Confirm your platform supports secure uploads, audit trails, and required authentication before enabling online submissions.

  • File Formats: Accept PDF and DOCX with size limits set to prevent upload failures
  • Authentication: Email plus SMS or higher for identity assurance on sensitive records
  • Audit Trail: Capture IP, timestamp, and action log for each signer

Use integrations with case management systems (for example, court or probation databases) and cloud storage with role-based access controls to maintain secure records and ease reporting.

Core Sections Within a Professional Application

A complete Family Violence Education Program Application typically contains these essential sections to support intake, eligibility verification, and reporting.

Applicant Details

Name, DOB, contact, and government ID references to uniquely identify the participant and link to other records.

Referral Information

Court or agency name, case/docket number, referral date, and the reason for referral or order details.

Risk/Needs Screening

Brief screening elements or checkbox indicators that help the provider plan intake and safety considerations.

Accommodations

Space to request language interpretation, physical accommodations, or scheduling exceptions for documented needs.

Consent and Acknowledgment

Signatures confirming program rules, confidentiality limits, and consent to data sharing with the referring authority.

Provider Use

Fields for intake staff: enrollment date, class assignment, attendance log, completion status, and reporting notes.

Supporting Documents and Export Options

Programs often require or generate companion documents; choose export formats that preserve signatures and audit metadata for compliance.

Referral Attachment

Attach a PDF of the court order or referral letter. PDFs retain layout and are preferred for legal exhibits.

Intake Summary

Generate a signed PDF summary for the case file that includes the audit trail and signer attestations.

Attendance Records

Export CSV or Excel reports for batch reporting to courts or probation officers.

Privacy Addendum

Provide a HIPAA or local privacy notice as a downloadable PDF when health-related information is collected.

Essential Data Items to Capture (Minimum Set)

Applicant Name: Full legal name
Date of Birth: MM/DD/YYYY
Referral Source: Court or agency
Case Number: Docket or referral ID
Signature: Signed consent
Contact: Phone and email

Common Pitfalls to Avoid

  • Incomplete case numbers or missing court orders cause processing delays and re-submissions.
  • Mismatched names between the application and court documents can prevent enrollment verification.
  • Using informal dates or nonstandard formats (e.g., DD-MM-YYYY) leads to validation failures.
  • Failure to capture signature consent for electronic records may invalidate the electronic signature under ESIGN.

Consequences of Errors or Noncompliance

Administrative Delay: May extend supervision or postpone program start
Court Sanctions: Potential hearings for failure to comply with court-ordered programs
Record Rejection: Incomplete or unsigned applications may be rejected
Privacy Violation: Improper handling of health data can trigger HIPAA concerns
Data Mismatch: Incorrect identifiers can break reporting chains
Loss of Credit: Missing attendance can lead to noncompletion findings

Typical Timelines and Processing Expectations

Timeframes vary by jurisdiction and whether the referral is court-ordered or voluntary; these are common expectations for intake and reporting.

Application Submission:

Submit within 7–14 days of referral to avoid scheduling delays

Intake Scheduling:

Provider typically schedules orientation within 14–30 days

Attendance Reporting:

Providers often report monthly or at course completion to referring agency

Completion Certification:

Certificate issued upon meeting attendance and curriculum requirements

Noncompliance Notice:

Reported to referring agency immediately on missed required sessions

Key Milestones from Referral to Certification

A typical milestone sequence shows intake and reporting checkpoints from initial referral through final certification.

01

Referral Received

Referral or court order is logged and assigned a case number

02

Application Completed

Applicant returns completed form with required attachments

03

Intake Appointment

Initial assessment and orientation are completed

04

Course Completion

Provider issues completion notice and sends report to the referring entity

Comparison: Typical eSignature Pricing and Core Capabilities

The table below compares starting prices and common capabilities across vendors, with signNow listed first for parity. Verify plan details with each vendor before purchase.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial Yes, 7-day free trial Yes Yes Yes Yes
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

Frequently Asked Questions and Troubleshooting

Answers to common questions about completing, submitting, and validating the Family Violence Education Program Application.


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