Name: Case No: Plea Date: GUILTY PLEA COLLOQUY You are present before this Court because you or your lawyer has stated that you wish to plead guilty to some or all of the criminal offenses which you have been charged. Please answer fully all of the questions on this document. If you do not understand any questions, you should answer “yes” or “no”, or fill in another appropriate answer. This is a sworn statement. After you have finished reading this form and filling it out, you should sign it on the last page, on the last line that says “Defendant”. You should also initial each page at the bottom, but only if you have read and have understood that page. If there is anything that you do not understand, you should tell your lawyer and the judge who hears your case, so that they can explain it to you fully, to make sure that you understand all your rights. Most of these questions can be answered “yes” or “no”. Where general information is requested, please answer fully. 1. What is your full name? 2. Do you wish to plead guilty to the charges of as laid out in criminal action . 3. How old are you? . 4. How far did you go in school? . 5. Do you read and write the English language? . 5a. Have you had an opportunity to read the charging pending against you? . 5b. Therefore do you know exactly what you are charged with and what you are pleading to? . American LegalNet, Inc. www.FormsWorkflow.com 6. Have you ever been in a mental institution or received treatment for a mental disease? . 7. Have you had any alcoholic beverages or drugs within the last 24 hours? . 8. Have you fully discussed your case with your attorney and are you fully satisfied that he know all the facts of your case and has had sufficient time to look into any questions either he or you may have about the case? . 8a. Are you satisfied with your attorney? . 9. Do you understand that even though you are guilty or may be guilty you are presumed to be innocent, and have a right to go to trial either before a judge or before a jury of 12 individuals and the Commonwealth must prove to the satisfaction of each and every one of the 12 jurors or to the satisfaction of the judge that you are guilty beyond a reasonable doubt? . 9a. Do you understand that you and your attorney have a right to participate in the selection of a jury? . 10. Do you understand that if you want to go to trial your attorney will be permitted to cross-examine the Commonwealth’s witnesses and to call witnesses on your behalf, but if you plead guilty, you will lose the right to call witnesses or to cross-examine the Commonwealth witnesses? . 11. Do you understand that by pleading guilty your are admitting that you did the things you are charged with and that if you plead not guilty, the Commonwealth cannot force you to take the stand and either admit or deny that you did the things you are charged with? . 12. Do you understand that by pleading guilty you are giving up your right to appeal any question in this case except for those concerning the right of this Court to try you (jurisdiction over the submit matter) or the legality or propriety of the sentence imposed? . 2 American LegalNet, Inc. www.FormsWorkflow.com 13. State specifically in detail any plea agreement with the District Attorney. 13a. Has the District Attorney made any other promises to you in exchange for your guilty plea other than what is mentioned above? . 13b. Have you been threatened or coerced in any manner to enter this guilty plea? . 14. Do you understand that the Court is not bound by the agreement you made with the District Attorney? . 15. Do you understand that the maximum penalty to the charges you are pleading guilty to is: . 15a. If you are pleading guilty to more than one charge, do you understand that the judge may imposed consecutive sentences? . . 15b. Do you understand that certain crimes carry mandatory minimum penalties? Did you attorney advise you that any mandatory penalties apply to your case? If the preceding answer is yes, state the mandatory provisions that apply to your case. . . 16. The elements of the crime charged are as follows: 3 American LegalNet, Inc. www.FormsWorkflow.com 16a. Do you understand these are the elements of the crimes charges that you are pleading to? . 17. The District Attorney indicates that this is what you did on the date of the crime charged. 18. Do you admit that you did the above stated act? . 19. Understanding the full meaning of the plea of guilty as stated above, do you still wish to plead guilty? . I affirm that I have read the above document in its entirety and have reviewing it with my attorney. I affirm that I am aware of the full implications of pleading guilty and nevertheless wish to plead to the specified offense(s). I further affirm that my signature on this Guilty Plea Colloquy and initials on each page of this document are true and correct. DATE: Defendant I, , Esquire, Attorney for state that I have advised my client of the contents and meanings of the document; it is my belief he/she fully comprehends the implication of pleading guilty and is pleading guilty of his/her own free will. Attorney for Defendant 4 American LegalNet, Inc. www.FormsWorkflow.com