________________________________ COURT

______________________ County, Arizona

STATE OF ARIZONA Plaintiff

[CASE/COMPLAINT NO.]

-vs-

NOTICE OF

RIGHT TO COUNSEL

______________________________________

AND WAIVER

Defendant (FIRST, MI, LAST)

READ THE ENTIRE FORM CAREFULLY BEFORE SIGNING IT

You have elected to proceed without an attorney either because:

[ ] you do not want an attorney,

[ ] the Court has determined that you are not entitled to a court- appointed attorney and you choose not to retain one.

The purpose of this form is to notify you of your right to an attorney, of the ways in which an attorney can be important to you in this case, and also to allow you to give up your rights if you so choose.

I understand that I am charged with the following crime(s) under the laws of Arizona:

______________________________________

which is a class ___ [ ] felony [ ] misdemeanor

______________________________________

which is a class ___ [ ] felony [ ] misdemeanor

______________________________________

which is a class ___ [ ] felony [ ] misdemeanor

______________________________________

which is a class ___ [ ] felony [ ] misdemeanor

______________________________________

which is a class ___ [ ] felony [ ] misdemeanor

I understand that if I am found guilty, I can be given a severe punishment, including incarceration [ ] in the Arizona State Prison, [ ] in the __________ County Jail, [ ] a fine, or other penalty.

I understand that under the Constitutions of the United States and the State of Arizona, I have the right to be represented by an attorney at all critical stages of this criminal case: before trial, at trial itself, during proceedings to determine what sentence should be imposed if I am found guilty, and for an appeal. I understand that, for certain offenses, if I am unable to obtain the services of an attorney without incurring substantial hardship to myself or to my family, one will be appointed for me at a reduced cost or at no cost to me.

I understand that the services of an attorney can be of great value, for example: in determining if the charges against me are sufficient as a matter of law; whether the procedures used in investigating the charges and obtaining evidence against me, including the lawfulness of any search, seizure or police questioning; if an act I may have committed actually amounts to the crime for which I am charged; if I have any other valid defense to the charges; if I am found guilty, whether I should be placed on probation, be required to pay a fine, or be sentenced to a term of incarceration; or if appellate review would be justified. I understand that, if I am found guilty of the offense charged, the Court may sentence me to a term of incarceration, even though I have given up my right to an attorney.

RIGHT TO AN ATTORNEY AT ANY TIME

I understand that I can change my mind about having an attorney at any time by asking the judge to appoint an attorney for me or by hiring my own attorney. I also understand that I will not be entitled to repeat any part of the case already held or to delay scheduled court proceedings based solely on changing my mind about having an attorney.

CERTIFICATION AND WAIVER

I certify that I have read and understand all of the above, and I hereby waive my right to an attorney in this case, and to have an attorney appointed at a reduced cost or at no cost to me, for eligible offenses, if I cannot afford one.

DO NOT SIGN THIS FORM UNLESS YOU HAVE READ IT COMPLETELY, OR HAD IT READ TO YOU AND UNDERSTAND IT FULLY.

DO NOT SIGN THIS FORM IF YOU WANT AN ATTORNEY.

Dated

Defendant

Interpreter

FINDING

After advising the defendant of the dangers and disadvantages of self-representation, the Court finds that the defendant’s waiver of counsel is knowing, voluntary, and intelligent.

Dated

Judicial Officer’s Signature