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2. Defendant's Name
4. Address
6. City
7. State
8. Zip
10. Phone Number
11. Citation Number(s)
15. Plea of Guilty and Waiver of Counsel - Check All

    I, the undersigned defendant, enter a plea of guilty to the charge(s) pending against me. By pleading guilty, I admit that I committed the offense(s) with which I am charged and that I have been advised of the following rights:

    1. To a trial; to be present at my trial and question witnesses against me; to secure a court document ordering witnesses to appear in my defense and testify at my trial;
    2. To no testify at my trial and not have my silence held against me;
    3. To be represented by an attorney; to have an attorney appointed for me if I am found by the judge to be indigent;
    4. To be fully advised of the charge(s) to which I plead guilty;
    5. To be fully advised of the minimum penalty provided by law and the maximum penalty provided by law;
    6. To be fully advised that by pleading guilty, I waive my right to a trial.
17. Defendant's Signature (Type Name)
    I now have been advised of, and understand that my plea of guilty will result in my giving up all of the above rights, and that I freely and voluntarily give up those rights, and I plead guilty to the above charge(s). I voluntarily and without the result of force or threats or promises, waive my right to counsel. UNDERSTANDING THESE RIGHTS AND I PLEAD GUILTY TO THE ABOVE CHARGE(S).
18. Date/Time
    Date/Time

    Date/Time
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