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: ____________
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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: ____________
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____________
____________
____________
(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:
2. Counsel for above-named defendant3. Mental Health Information Service4. 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]
____________
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N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. II, Forms (cf. Part 110), form U