THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) CHINS ACKNOWLEDGMENT AND WAIVER OF RIGHTS I, , my attorney being , knowingly, intelligently, freely and voluntarily make the following statements which I understand apply to each and every juvenile petition (if there is more than one) to which I admit (which means to "plead true"). I understand I am alleged to have committed the following act(s): I UNDERSTAND that I do not have to admit to the act(s) and that even after signing this Acknowledgment and Waiver of Rights, I still do not have to admit to the act(s). I UNDERSTAND that by admitting to the act(s), I am giving up the following constitutional rights: MY RIGHT to a speedy trial. MY RIGHT to see, hear and question all witnesses against me and question them myself or through my lawyer. MY RIGHT to keep silent and not testify against myself, if I choose, and to not have my silence used against me. MY RIGHT to have the judge order into court all evidence and witnesses in my favor. MY RIGHT not to be found in need of services except by proof beyond a reasonable doubt on all elements of the allegations(s), which have been explained to me by my lawyer. MY RIGHT to have the Court keep out evidence or any confessions which may have been obtained in violation of my constitutional rights. MY RIGHT to appeal to the Supreme Court, on questions of law, if the petition is found to be true. I GIVE UP ALL THE ABOVE RIGHTS OF MY OWN FREE WILL. I UNDERSTAND that I am admitting to the truth of the act(s) in the CHINS petition(s), and that if the Court accepts my admission I may be found to be in need of services. I understand my case will be given to a Juvenile Service Officer for a background investigation to be reviewed by the Judge before I am found to be in need of services. This report may contain a recommendation for that disposition. I AM ADMITTING to the act(s) because the content(s) of the CHINS petition(s) is(are) true. I admit that I did the act(s) alleged in the CHINS petition(s). No force has been used upon me. No promises have been made to me by any member of the police department, prosecutor or anyone else in an effort to have me admit to the act(s) except as follows: NHJB-2218-DF (09/03/2013) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: CHINS ACKNOWLEDGEMENT AND WAIVER OF RIGHTS I UNDERSTAND that the Court does not have to follow the recommendation of the police, prosecutor, Juvenile Probation and Parole Officer or anyone else as to recommended services. I UNDERSTAND that under certain circumstances, if the Court does not follow any recommendation, I may be able to take back my plea of true and have a trial. I UNDERSTAND that, within the limits of the law, the Judge may order any services s/he feels are fair. My attorney, whose services I am satisfied with, has explained to me the penalties that the judge may give me as disposition for the act(s) I have admitted, including placement on conditional release; attendance at individual or family counseling; release in the care and supervision of a relative, group home, or crisis home; uncompensated community service; attendance at an after-school or evening program; the payment of a fine up to $250; payment of restitution; and/or loss or denial of driver's license for a minimum of 90 days but not more than a year. I UNDERSTAND that if I am found to be in need of services for any offense involving the sale, possession, use or abuse of alcohol, or of a controlled drug or drug analog, the Court may and the Director of the Division of Motor Vehicles shall revoke or deny me a driver's license for not less than 90 days or more than one year for a first offense and not less than six months or greater than two years for a subsequent offense pursuant to RSA 263:56B I do not have any questions at this time of my attorney or anyone else. If there are any questions of the Court or if there is anything I would like to say before disposition of this case, my attorney will let the Court know at the time of my admission to the act(s). I understand that I may ask to have a copy of this Acknowledgment and Waiver of Rights form. Date Juvenile Parent / Guardian / Custodian As counsel for the juvenile, I have thoroughly explained to the juvenile all the above, including the nature of the allegations, the elements of the act(s) which the State must prove beyond a reasonable doubt, and the maximum and minimum dispositional orders. I believe the juvenile fully understands the meaning of this Acknowledgment and Waiver of Rights, that s/he has the mental capacity to evaluate these rights; I believe that s/he does understand and evaluate these rights and does knowingly, intelligently and voluntarily waive all of his/her rights as set forth herein. Date Attorney for the Juvenile The undersigned Judge has asked the juvenile if s/he (1) understands the allegations against him/her; (2) understands the possible penalties; and (3) understands the fact that s/he is giving up his/her constitutional rights. The undersigned finds that the juvenile has the mental capacity to evaluate this Acknowledgment and Waiver of Rights and finds that s/he does knowingly, intelligently and voluntarily waive those rights. Date Signature of Judge Printed Name of Judge NHJB-2218-DF (09/03/2013) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com