APPLICATION FOR ADJOURNMENT IN CONTEMPLATION OF DISMISSAL PART 1 - To Be Completed Prior To Granting of ACD Westchester County, Court of : __________________________ -----------------------------------------------------

x The People of the State of New York - against Defendant ---------------------------------------------------- x State of New York: County of Westchester, City, Town, Village of ________________ Docket No.: ________________________

ss:

I, _________________________, being duly sworn, depose and say, that I make this application for an adjournment in contemplation of dismissal pursuant to the Criminal Procedure Law and in support of this application, I state that: 1. I have never been arrested before. 2. I have never been convicted of any violation or crime. 3. I have never received Youthful Offender treatment. 4. I have never had an adjournment in contemplation of dismissal for any prior case in any court. 5. In consideration of my receiving an ACD as consented to by the District Attorney, I agree that the facts as set forth in the accusatory instruments against me shall not form the basis of a civil action against the complainant herein or members of any law enforcement agency herein. Sworn to before me this _________ day of ________________, ________ _____________________________________________ Defendant _____________________________________________ Attorney for Defendant PART II - To Be Completed Prior To Expiration Date State of New York: County of Westchester, City, Town, Village of ________________

ss:

I, ___________________________________, being duly sworn, depose and say, having been granted an adjournment in contemplation of dismissal on __________________________________, that since then: 1. I have never been arrested. 2. I have never been convicted of any violation or crime. 3. I have not received Youthful Offender treatment. 4. I have not been granted an adjournment in contemplation of dismissal in any court. Sworn to before me this _________ day of ________________, ________ _____________________________________________ Defendant _____________________________________________ Attorney for Defendant