TENDER OF PLEA OR ADMISSION & WAIVER OF RIGHTS NAME OF DEFENDANT DOCKET NO. Trial Court of Massachusetts District Court Department COURT DIVISION SECTION I COUNT NO. CONDITIONAL TENDER OF PLEA OR ADMISSION GUILTY PLEA ADMISSION TO FACTS SUFFICIENT BINDING PLEA WITH CHARGE CONCESSION FOR A FINDING OF GUILTY UNDER RULE 12(b)(5)(A) DEFENDANT'S PROSECUTOR'S JUDGE'S DISPOSITION UPON REJECTING A BINDING PLEA OR RECOMMENDATION(S) RECOMMENDATION(S) NON-BINDING RECOMMENDATION (Include all fees, costs, and conditions of (Required when Prosecutor disagrees with probation) Defendant's recommendations) SUSPENDED SENTENCES MAY BE IMPOSED FROM AND AFTER UPON A PROBATION VIOLATION UNLESS OTHERWISE NOTED. ANY COUNT PLACED ON FILE may be removed from the file at any time and have a sentence imposed (or be scheduled for trial if no guilty finding has been made): (1) at the defendant's request, or (2) if a related conviction or sentence is reversed or vacated, or (3) if it is shown by a preponderance of evidence that the defendant committed a new criminal offense, or (4) if it is shown by a preponderance of evidence that : The prosecutor may not request that the charge be removed from the file after: __________________________________________ (date). DIST. / MUN. CTS. R. CRIM. P. 4(c) REQUIRES COUNSEL TO CONSULT WITH THE PROBATION DEPARTMENT REGARDING PROBATIONARY TERMS. SIGNATURE OF DEFENSE COUNSEL OR PRO SE DEFENDANT DATE SIGNATURE OF PROSECUTOR DATE X THE COURT SIGNATURE OF JUDGE X ACCEPTS DEFENDANT'S TENDER REJECTS DEFENDANT'S TENDER DATE X DEFENDANT'S DECISION WHEN COURT REJECTS DEFENDANT'S RECOMMENDATION: Defendant WITHDRAWS the tendered plea or admission SIGNATURE OF DEFENSE COUNSEL DATE Defendant ACCEPTS judge's disposition set forth above SIGNATURE OF DEFENDANT DATE X DC-CR 22 (Rev. 5/15) (front) X American LegalNet, Inc. www.FormsWorkFlow.com SECTION II DEFENDANT'S WAIVER OF RIGHTS (G.L. c. 263, § 6) & ALIEN RIGHTS NOTICE (G.L. c. 278, § 29D, MASS. R. CRIM. P. 12) I am not now under the influence of any drug, medication, liquor, or other substance that would interfere with my ability to fully understand the constitutional and statutory rights that I am waiving when I plead guilty or admit to sufficient facts to support a guilty finding. I have decided to plead guilty, or admit to sufficient facts, freely and voluntarily upon the conditions which I have tendered in Section I. My guilty plea or admission is not the result of force or threats, promises, or other assurances. I understand and acknowledge that I am voluntarily giving up the right to be tried by a jury, or by a judge without a jury, on these charges. I understand that the jury would consist of six jurors chosen at random from the community, and that I could participate in selecting those jurors, who would determine unanimously whether I was guilty or not guilty. I understand that, by entering my plea of guilty or admission, I will also be giving up my right to confront, cross-examine, and compel the attendance of witnesses; to present evidence in my defense; to remain silent and refuse to testify or provide evidence against myself, all with the assistance of a defense attorney; and to be presumed innocent until proven guilty by the prosecution beyond a reasonable doubt. I am aware of the nature and elements of the charge(s) to which I am entering my guilty plea or admission. I am also aware of the nature and range of the possible sentence(s); I am aware that sentences can be imposed one after the other. I have been advised if my plea of guilty or admission to the charges could trigger the provisions of the sex offender registration statute or commitment as a sexually dangerous person under G.L. c. 123A, §12. I understand that if I am not a citizen of the United States, the acceptance by this court of my plea of guilty, plea of nolo contendere, or admission to sufficient facts may have consequences of deportation, exclusion from admission to the United States, or denial of naturalization, pursuant to the laws of the United States. If the offense to which I am pleading guilty, nolo contendere, or admitting to sufficient facts is under federal law one that presumptively mandates removal from the United States and federal officials decide to seek removal, it is practically inevitable that this disposition would result in deportation, exclusion from admission, or denial of naturalization under the laws of the United States. If any charge is being placed on file: I freely and voluntarily consent to the filing of that charge on the conditions listed on the front of this form. I understand that I have a right at any time to have the court remove it from the file and impose sentence (or schedule it for trial if no guilty finding has been made). I understand that the prosecutor may request the court to remove it from the file and impose sentence (or schedule it for trial if no guilty finding has been made) if a related conviction or sentence is reversed or vacated, or if the prosecutor proves by a preponderance of evidence either that I committed a new criminal offense or that any other condition listed on this front of this form has occurred. The prosecutor may do so at any time (or, if a time limit is listed on the front of this form, at any time until that date). I understand that, if the charge is removed from the file and I am sentenced, it may result in additional punishment in this case. SIGNATURE OF DEFENDANT DATE X I have translated this document for the defendant. SIGNATURE OF INTERPRETER SECTION III DEFENSE COUNSEL'S CERTIFICATE (G.L. c. 218, § 26A) As required by G.L. c. 218, § 26A, I certify that I have explained to the defendant the legal rights and consequences referred to in Section II above. SIGNATURE OF DEFENSE COUNSEL BBO# DATE X SECTION IV JUDGE'S CERTIFICATION I, the undersigned Judge of the District Court, addressed the defendant directly in open court. I made appropriate inquiry into the education and background of the defendant and am satisfied that the defendant fully understands all of the defendant's rights as set forth in Section II above, and that the defendant is not under the influence of any drug, medication, liquor, or other substance that would impair the defendant's ability to fully understand those rights. I find, after a colloquy with the defendant, that the defendant has knowingly, intelligently, and voluntarily waived all of the rights as explained during these proceedings and as set forth in this