IN THE DISTRICT COURT OF THE

______________ CIRCUIT

_____________ DIVISION

WAIVER OF PHYSICAL PRESENCE: SUBMISSION OF PLEA; PRO SE DEFENDANT; ATTACHMENT “A” Case Number:

STATE OF HAWAI’I vs. (DEFENDANT) Police Report Number:

CHARGE(S): VIOLATION OF H.R.S. SECTION(S) AMENDED CHARGE(S):

In accordance with Rule 43, Hawai’i Rules of Penal Procedure:

[ ] I understand that the maximum possible penalties are:

OFFENSE # 1: __________________ H.R.S. Section: ____________________

$___________ Fine or _____ days/months/year in jail or both.

OFFENSE # 2: __________________ H.R.S. Section: ____________________

$___________ Fine or _____ days/months/year in jail or both.

OFFENSE # 3: __________________ H.R.S. Section: ____________________

$___________ Fine or _____ days/months/year in jail or both.

OFFENSE # 4: __________________ H.R.S. Section: ____________________

$___________ Fine or _____ days/months/year in jail or both.

OFFENSE # 5: __________________ H.R.S. Section: ____________________

$___________ Fine or _____ days/months/year in jail or both.

OFFENSE # 6: __________________ H.R.S. Section: ____________________

$___________ Fine or _____ days/months/year in jail or both.

OFFENSE # 7: __________________ H.R.S. Section: ____________________

$___________ Fine or _____ days/months/year in jail or both.

OFFENSE # 8: __________________ H.R.S. Section: ____________________

$___________ Fine or _____ days/months/year in jail or both.

OFFENSE # 9 __________________ H.R.S. Section: ____________________

$___________ Fine or _____ days/months/year in jail or both.

OFFENSE #10: __________________ H.R.S. Section: ____________________

$___________ Fine or _____ days/months/year in jail or both.

DATED this _______________ day of _______________, 20___.

________________________________________

Signature of Defendant