New York Codes, Rules and Regulations › Title 22 - JUDICIARY › Subtitle D - Forms › Chapter II - Cpl Section 330.20 Forms › Forms (cf. Part 110) › Form U - Application for furlough order and notice of application

Current through Register Vol. 46, No. 28, July
				  10, 2024
FORM U
APPLICATION FOR A FURLOUGH ORDER
AND NOTICE OF APPLICATION
STATE OF NEW YORK
SUPREME COURT COUNTY COURT
PART: ________ COUNTY: ____________
________
IN THE MATTER
of
An Application for a Furlough Order
Pursuant to C PL 330.20 in Relation
					 to
________
Defendant
________
(1) The undersigned is authorized by
				  the State Commissioner of Mental Health to submit this application for a
				  furlough order for and on behalf of the said Commissioner.
(2) his application for a
				  furlough order is being submitted to the following court: [check one and print
				  name and address of indicated court]
Court that issued the commitment order if
					 the above-named defendant is now in custody pursuant to such order:
					 ____________
____________
County Court of the county wherein the
					 facility in which the defendant is confined is located: ____________
____________
Term of the Supreme Court for the county
					 wherein the facility in which the defendant is confined is located:
					 ____________
(3) This application for a furlough
				  order is made pursuant to subdivision 10 of C PL 330.20.
(4) The above-named defendant
				  was committed to the custody of the State Commissioner of Mental Health for
				  confinement in a secure facility for care and treatment pursuant to a
				  commitment order issued under the provisions of subdivision 6 of C PL 330.20
a recommitment order issued under the
					 provisions of subdivision 14 of C PL 330.20
by the following court on the following
					 date:
[Name of court] ____________
[Date of order] ____________
(5) Subsequent to
				  the issuance of the order referred to in paragraph (4) of this application, the
				  following court issued a first retention order on the following date:
[Name of court] ____________
[Date of first retention order]
					 ____________
(6) Subsequent to the issuance of the
				  first retention order referred to in paragraph (5) of this application, the
				  following court issued a second retention order on the following date:
[Name of court] ____________
[Date of second retention order]
					 ____________
(7) Following the issuance of the
				  second retention order referred to in paragraph (6) of this application, the
				  following court issued a subsequent retention order on the following date:
[Name of court] ____________
[Date of each subsequent retention order,
					 including last subsequent retention order] ____________
(8) Pursuant to the order
				  referred to in paragraph (4) paragraph (5) paragraph (6) paragraph (7) of this
				  application, the above-named defendant is currently confined in the following
				  facility of the State Office of Mental Health:
____________.
(9) This application is made
				  upon the ground that the undersigned is of the view that, consistent with the
				  public safety and welfare of the community and the defendant, the clinical
				  condition of the defendant warrants a granting of the privileges authorized by
				  a furlough order.
(10) The annexed psychiatric report is
				  made a part of this application for a furlough order and supports the view
				  stated by the undersigned in paragraph (9) of this application for the
				  following reasons:
____________
____________
____________
____________
____________
(11) Written notice of this
				  application for a furlough order has been given to the above-named defendant,
				  counsel for the defendant, the Mental Health Information Service and the
				  District Attorney. This written notice was given at least 10 days prior to the
				  date that this application will be submitted to the court indicated in
				  paragraph (2) of this application.
(12) No previous application for a
				  furlough order has been made to any court.
WHEREFORE, the undersigned respectfully
					 requests that this application be granted and that a furlough order issue
					 authorizing the Commissioner of Mental Health to allow the above-named
					 defendant to temporarily leave the facility for ________ [here insert a period
					 of time not exceeding 14 days] with or without the constant supervision of one
					 or more employees of the facility and upon such terms and conditions that the
					 court deems necessary or appropriate.
______________
Signature
______________
Type or Print Name
______________
Title
Dated: ________
NOTICE OF APPLICATION FOR A FURLOUGH
					 ORDER
To:
1. Above-named defendant
2. Counsel for above-named
				  defendant
3. Mental
				  Health Information Service
4. District Attorney of ________ County
PLEASE TAKE NOTICE that the above
					 application for a furlough order will be submitted to the court indicated in
					 paragraph (2) of the application on: [date and time]
____________
____________