THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) JUVENILE ACKNOWLEDGMENT AND WAIVER OF RIGHT TO JURY TRIAL I , have been sentenced after a contested adjudicatory hearing and a finding of true on the charges of the juvenile petition. Part of my sentence includes suspended, deferred, or imposed incarceration at an adult facility. I UNDERSTAND that I cannot be committed to an adult facility without first being afforded the right to a jury trial, or waiving my right to a jury trial. I am represented by , a lawyer admitted to practice law in the State of New Hampshire. I am satisfied with my lawyer and all explanations have been clear. I UNDERSTAND that I do not have to waive (give up) my right to a jury trial. I UNDERSTAND that by waiving my right to a jury trial I am giving up the following constitutional rights: MY RIGHT under the Constitution of the United States and the New Hampshire Constitution to be tried by an impartial jury. MY RIGHT to have a twelve-person jury decide whether the charges against me are true or not true by a unanimous verdict. MY RIGHT to testify or not to testify before a jury. I further understand that if I elect not to testify before a jury, my silence could not be used against me by the jury. No force has been used upon me, nor have any threats been made to me by any member of the Prosecutor's Office or anyone else to have me waive my right to a jury trial. I UNDERSTAND the entire content of this Acknowledgment and Waiver of Right to Jury Trial, and I freely and voluntarily sign this form below. I also understand that I may have a copy of this form upon request. Date Juvenile Parent / Guardian / Custodian NHJB-2252-DF (12/06/2006) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: JUVENILE ACKNOWLEDGMENT AND WAIVER OF RIGHT TO JURY TRIAL As counsel for the juvenile, I have thoroughly explained to the juvenile all of the above. I believe the juvenile fully understands the meaning of this Acknowledgment and Waiver of Right to Jury Trial, and that he/she is not under the influence of drugs or alcohol, and that he/she knowingly and intelligently waives his/her right to a jury trial. Date Attorney for the Juvenile I hereby certify that I have examined the juvenile concerning this Acknowledgment and Waiver. Based upon that examination, I find that the juvenile understands his/her right to a jury trial. I find that the juvenile is not under the influence of drugs or alcohol and he/she intelligently, knowingly and voluntarily waives his/her right to a jury trial. Date Signature of Judge Printed Name of Judge NHJB-2252-DF (12/06/2006) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com