________________________________ COURT

______________________ County, Arizona

STATE OF ARIZONA Plaintiff

[CASE/COMPLAINT NO.]

-vs-

Defendant (FIRST, MI, LAST)

(A)

An opinion as to the mental status of the defendant at the time of the offense;

(B)

If the expert determines that the defendant suffered from a mental disease, defect or disability at the time of the offense, the relationship of the disease, defect or disability to the alleged offense.

IT IS FURTHER ORDERED that if the defendant is not in custody, the defense attorney is to contact the experts at [names and phone numbers] ____________________ within two (2) working days of this order to schedule a time for the defendant's examination and use due diligence to secure the defendant's attendance at the examination.

IT IS FURTHER ORDERED that the prosecutor and the defense attorney provide to the experts at [addresses] _______________ the motion to have defendant's mental condition examined, copies of police reports, previous mental health reports and any other appropriate material for the examination.

IT IS FURTHER ORDERED that payment of the cost of the examination of the defendant is the responsibility of the ____________________ pursuant to ARS § 13-4505.

IT IS FURTHER ORDERED that a hearing will be held in __________ court on the ___ day of __________, 20 ___ at __________ a.m./p.m.

IT IS FURTHER ORDERED that the experts will submit the written reports at least 10 days prior to the hearing date to __________ which will seal the originals and provide copies to the defense attorney. The defense attorney shall provide redacted copies of the reports to the court and the prosecutor's office within 24 hours of receipt.

Signature of Judicial Officer

Date

Defense Attorney (please print name)

Prosecutor (please print name)

Telephone No.

Bar No.

Telephone No.

Bar No.

Mailing Address

Mailing Address

City State Zip

City State Zip