[29 Pa.B. 809]

[Continued from previous Web Page]

Order of Referral

(to be used when a request for supervised bail
is submitted after bail has been set)

Caption

   And now,                               , upon motion of the defendant, the request for supervised bail is referred to the Probation Office. That office shall evaluate defendant, explain the contents of the application, acknowledgment and consent, and when defendant has signed that form, submit a recommendation to this court via the District Attorney, with the form attached.

By the Court,
__________
Judge

Notice of Rescission and Order

Caption

To the defendant:

   Your supervised bail has been rescinded and you are subject to imprisonment until you have posted regular bail or until supervised bail is reinstated. You have the right to post regular bail unless and until that bail is revoked by the bail authority. Both you and the Probation Office have the right to demand a hearing. You may either demand that hearing immediately, or file your request promptly with either the court or district justice. Promptness will be determined in light of all circumstances, but generally requires filing within ten days. You may request that supervised bail be reinstated and/or that regular bail be modified or changed. The Probation Office may request that regular bail be revoked and/or that any monetary conditions of your supervised bail be forfeited.

Dated:  __________	__________  Probation Officer
I acknowledge receipt of this notice. I [  ]  do   [  ]  do not request a hearing.
Dated:  __________	__________  Defendant

Order

   And Now,                , a hearing is scheduled for  ______ , in a courtroom to be designated. The Probation Office shall notify all interested persons.

By the Court,
 
__________
Judge

   Forms for internal use may be adopted by the Probation Office at any time.

Probation Office Report

   [  ]  Defendant has signed all necessary papers and has been released on supervised bail.

   [  ]  Defendant has signed all necessary papers and has been released on supervised bail.

   [  ]  Defendant has either not agreed to all conditions, has not signed all necessary papers, or has not appeared as directed by order and supervised bail has been rescinded.

   [  ]  The Probation Office recommends that special conditions  _________________   be added before defendant is released on supervised bail. Defendant [  ]  has [  ]  has not agreed to additional conditions.

   (The next items to be checked when defendant has been referred to the Probation Office for evaluation and recommendation.)

   [  ]  The Probation Office recommends that defendant be considered eligible for supervised bail subject to standard conditions of the supervised bail program and additional conditions  _________________ .

   [  ]  The Probation Office recommends that defendant be considered ineligible for supervised bail.

Dated:  __________

__________  Probation Officer

District Attorney's Acknowledgment
(In all cases)

   I acknowledge that I have received notice of defendant's supervised bail status. (For referral cases only)  [  ]  I acquiesce in supervised bail  [  ]  I oppose supervised bail  [  ]  I do not oppose supervised bail if condition(s)  ______   are added.

Dated:  __________

__________  District Attorney

   If defendant conditionally agrees to conditions and level of supervision and requests a hearing, check here [  ]  and sign.

Dated:  ___________________________

Order
(after referral)
caption

   AND NOW,

   The following apply, if checked:

   [  ]  Defendant's request for supervised bail is denied.

   [  ]  Defendant may be released on supervised bail subject to conditions in the application, acknowledgment and consent.

   [  ]  Defendant's obligation to post regular bail as a condition of release [  ]  is; [  ]  shall upon execution of all forms be, suspended and defendant may be released on alternative supervised bail for as long as defendant complies with conditions of supervised bail, and/or until such bail is rescinded, modified, or revoked. Supervised bail shall be subject to conditions of law, state and local rules of Court, as well as all other conditions incorporated in defendant's application, acknowledgement and consent. In addition, supervised bail shall be subject to the following conditions, as checked:

   [  ]  ROR [  ]  monetary condition in the sum of $  ______ , with cash percentage bail [  ]  available [  ]  not available; [  ]  Special conditions:   _________________  [  ]   payment by defendant
of a supervision or monitoring fee of $ _____  per  ______ .

   [  ]  defendant shall be under a continuing obligation to keep the Probation Officer informed of his employment and financial status.

   [  ]  house arrest

   [  ]  electronic monitoring

   Any probation officer having reasonable cause to believe that defendant has violated any condition of supervised bail may declare supervised bail to be rescinded and arrest defendant with or without a warrant. Upon arrest, defendant shall be committed to prison pending the posting of regular bail. The probation officer shall promptly file a notice of rescission and arrest with the appropriate court or district justice office and may request revocation of supervised and regular bail, as well as forfeiture of monetary conditions of supervised bail. Defendant may request that supervised bail be reinstated or that regular bail be modified.

By the Court,
__________
Judge

Rule 4010.  Bail Agency.

   For purposes of administering the supervised bail program, the Adams County Probation Office is designated as the bail agency for this court.

BAIL ASSESSMENT

Part I.  To be completed by the Probation Office

Defendant's name:  __________

CC Number:  __________

Charges:  __________
 
__________

Prior Record, if known:  __________
 
__________

Part II.  To be completed by Defendant

1.  State your address:	_________________	_________________	_________________
	Street
	_________________	_________________	_________________
	City	State	Zip

2.  State your telephone number:  (            )__________

3.  Where do you work?  __________

4.  How long have you worked there?  __________

5.  What is your take home pay?  __________

6.  Name the persons who are dependent upon you for support:

NAME	AGE	RELATIONSHIP	ADDRESS (If the same as yours, write same)
______	_____	______	_________________
______	_____	______	_________________
______	_____	______	_________________
______	_____	______	_________________
______	_____	______	_________________

7.  State your marital and living status:  [  ]  married, living with spouse;
[  ]  married, but separated;   [  ]  divorced;   [  ]  living with girl or boyfriend.

8.  Prior employment within 5 years:

Employers name	Period of employment	Reason for termination
_________________	_________________	_________________
_________________	_________________	_________________
_________________	_________________	_________________
_________________	_________________	_________________
_________________	_________________	_________________

9.  Do you  [  ]  own your own home;   [  ]  rent a home or apartment;
[  ]  live with a friend

10.  Do you have family members or a girl or boyfriend living in Adams County? [  ]  Yes;      [  ]  No
      State names and relationship:
__________
 
__________
 
__________

11.  Have you ever been treated or sought counseling or other treatment for a mental or emotional illness or problem?
[  ]  Yes;   [  ]  No;   If yes, when and by whom:  __________
Or for drug dependency?  [  ]  Yes;   [  ]  No:   If yes, when and by whom:   __________

12.  Do you consume alcoholic beverages?   [  ]  Yes;   [  ]  No
If so [  ]  beer; [  ]  wine; [  ]  whiskey      How many drinks per day?  ____

12a. Do you use non prescribed controlled substances?   [  ]  Yes;   [  ]  No;
[  ]  Declined;   If yes, what substance?  _________________

13.  Have you ever missed work because of alcohol consumption?
[  ]  Yes;   [  ]  No;      Have you been counseled or treated for alcohol abuse?    [  ]  Yes;   [  ]  No;   If yes, when and by whom:  __________

14.  Have you ever been convicted of an alcohol or drug related crime?
[  ]  Yes;      [  ]  No;      if yes, when and where:  __________

15.  Have you ever been released on bail before?   [  ]  Yes;      [  ]  No
If yes, when and where:  __________

16.  Have you ever failed to appear as directed or ordered in a criminal case?
If yes, was a bench warrant issued for your arrest?   [  ]  Yes;      [  ]  No
If yes, what happened:
__________
 
__________

17.  Describe any real estate you own in the State of Pennsylvania:

Location	Use	Your equity (value less liens)
______	______	_________________
______	______	_________________

18.  Describe any checking or bank accounts you own:

Bank	Address	Type	Balance
______	______	______	______
______	______	______	______

19.  State stocks, bonds, notes you own:

Stocks,bonds, CD, or note(s)	Where	Value
_________________	______	______
_________________	______	______

To be signed by defendant:

   I understand that any false statements made herein and which I do not believe are true, are subject to punishment by law in accordance with 18 Pa.C.S.A. § 4904.

__________ Date

__________   Defendant

For Probation Office Use:

Probation Officer's Name:  ___________________________

List questionable answers or those believed to be untrue.  __________
 
__________

Supervised bail [  ]  Is;      [  ]  Is not recommended.
__________
Probation Officer

[Pa.B. Doc. No. 99-224. Filed for public inspection February 12, 1999, 9:00 a.m.]

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