Fillable Form 200 00011 0 (Vermont Judiciary)

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Form 200 00011 0 (Vermont Judiciary)

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200-00011 – Application for Home Detention Program (08/2018) Page 1 of 2
STATE OF VERMONT
SUPERIOR COURT
CRIMINAL DIVISION
Unit
Docket No. __________________
STATE OF VERMONT v. DOB
APPLICATION FOR HOME DETENTION PROGRAM
1.
Charges:
Defendant is charged with the following offenses:
Docket No. Offense
___________________________ ____________________________________________________
___________________________ ____________________________________________________
___________________________ ____________________________________________________
2.
On ______________________
, Defendant was ordered:
☐ Held pending payment of $__________ in
cash on an Appearance Bond in the amount of $_________.
☐ Held pending payment of $__________ cash or Bail Bond with solvent securities.
3.
Defendant has been detained at a correctional facility in the custody of the Commissioner of
Corrections for
lack of bail. Defendant is currently unable to post bail
in the amount ordered by the court.
4.
If Defendant was approved for the Home Detention Program, he/she agrees to reside at the
following address:
Street & Apt. #, if any ___________________________________________________________________
Town/City ___________________________________ State: __________ Zip: __________
5.
The owner(s) of the residence is:
____________________________________________________________
6. The owner(s) or property manager’s phone number is: _________________________________________
7.
The residents of this household are:
_____________________________________________ _________________________________________
_________________________________________ _____________________________________
8. The Defendant’s contact number at the residence is: __________________________________________
9.
If other than Defendant, the owner of the residence approves of Defendant's residence at the
home and will
permit electronic surveillance equipment to be used at the residence.
10. Telephone coverage is required. Defendant must maintain a cell phone that is able to receive calls at
the residence, or the residence must have a landline.
Defendant’s Name
200-00011 – Application for Home Detention Program (08/2018) Page 2 of 2
11.
If approved for the program, Defendant requests that the court approve his/her absence from the
home for the
following purposes:
☐ Court appearances for these proceedings (no transport required)
☐ Employment at: ___________________________________________________________________
☐ Treatment Appointments at: _________________________________________________________
☐ Medical Appointments at: ___________________________________________________________
☐ Attorney Appointments at: __________________________________________________________
☐ Educational Services operated by the Department of Corrections. **
☐ Other approved absences: ___________________________________________________________
**All persons under the custody of the Commissioner of Corrections who are under 23 years of age and
have not received a high school diploma shall participate in the education program unless exempted by the
Commissioner per Title 28 VSA 120
12. If approved for the program, Defendant is willing to comply with his/her conditions of release, the
standard conditions for the Home Detention Program and any other conditions the court may order.
13. If approved for the program, Defendant will be financially responsible for any lost or damaged
electronic monitoring equipment that is assigned to him/her by the Department of Corrections.
Dated
_____________________________ _______________________________________
Signature of Applicant
cc: State's Attorney
Defense Attorney
Department of Corrections
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Form 200 00011 0 (Vermont Judiciary)

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Completed 19 July 2020

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