Before accepting your plea of not guilty, I will ask you certain questions. If you do not understand any question, please ask me to explain it to you.

1. What is your full name and what is your age?______________________________

2. Are you the person charged in the (indictment) (information) (warrant)

with the commission of the offense(s)?________________________________________

3. Do you fully understand the charge(s) against you?________________________

4. Have you discussed the charge(s) with your lawyer?________________________

5. Have you had enough time to discuss with your lawyer any possible defense

you may have to (this) (these) charge(s)?____________________________________

6. Have you given your lawyer the names of witnesses, and if so, are they

present?________________________________________________________________

7. Are you entirely satisfied with the services of your lawyer?______________

8. Are you entering this plea of not guilty freely and voluntarily?__________

9. Are you ready for trial today?____________________________________________

10. Do you understand that you are entitled to a trial by jury, but that you

can consent to trial by the judge without a jury?_____________________________

Have you discussed with your lawyer the advisability of trial by a jury or by the judge without a jury?__________________________________________________

Do you wish to be tried by a jury or by the judge without a jury?_____________

11. Do you understand all of the questions I have asked you?_________________

These questions were asked of the defendant in open court in the absence of a jury on_, 20_

____________________________________________

Signature of defendant

____________________________________________

Signature of attorney representing defendant