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

(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: