Defendant’s full name: JUDGMENT AND COMMITMENT ORDER IN THE CIRCUIT COURT OF _______________, ARKANSAS _____DISTRICT _____ DIVISION On _________________________ the Defendant appeared before the Court, was advised of the nature of the charge(s), of constitutional and legal rights, of the effect of a guilty plea upon those rights, and of the right to make a statement before sentencing. The Court made the following findings: DEFENDANT'S FULL NAME: DATE OF BIRTH: RACE: SEX: SID #: DEFENDANT'S ATTORNEY: PROSECUTING ATTORNEY OR DEPUTY: CHANGE OF VENUE FROM: Defendant was represented by ___ private counsel ___ public defender ___ appointed counsel ___ himself/herself Defendant made a voluntary, knowing and intelligent waiver of the right to counsel: ___ Yes ___ No There being no legal cause shown by the Defendant, as requested, why judgment should not be pronounced, a judgment of conviction is hereby entered against the Defendant on each charge enumerated, fines levied, and court costs assessed. The Defendant is sentenced to the Arkansas Department of Correction (A.D.C.) for the term specified on each offense shown below: -----------------------------------------------------------------------------------------------------------------------------------------------------TOTAL NUMBER OF COUNTS: -----------------------------------------------------------------------------------------------------------------------------------------------------Offense # 1 Docket #: Arrest Tracking #: A.C.A. # of Offense: Name of Offense: Seriousness Level of Offense: Criminal History Score: Presumptive Sentence: Sentence is a departure from the sentencing grid. ___ Yes ___ No. Offense is a ___felony ___misdemeanor. Classification of offense: ___A ___B ___C ___D ___U ___Y Sentence imposed: ___ months. Suspended imposition of sentence: ___ months. Defendant was sentenced as an Habitual Offender under A.C.A. 5-4-501, Subsection ___(a) ___(b) ___(c) ___(d). Sentence was enhanced by ______ months pursuant to A.C.A. __________________________. Defendant ___attempted ___solicited ___conspired to commit the offense. Offense date: Number of counts: Defendant was on ___probation ___parole at time of conviction. Commitment on this offense is a result of the revocation of Defendant's probation or suspended imposition of sentence. ___ Yes ___ No. Victim of the offense was ___under ___over the age of 18 years. Defendant voluntarily, intelligently, and knowingly entered a ___ negotiated plea of guilty or nolo contendere. ___ plea directly to the court of guilty or nolo contendere. Defendant ___ entered a plea as shown above and was sentenced by a jury. ___ was found guilty of said charge(s) by the court, and sentenced by ___the court ___a jury. ___ was found guilty at a jury trial, and sentenced by ___the court ___ a jury. ----------------------------------------------------------------------------------------------------------------------------------------------------– Page ___ of ___ American LegalNet, Inc. www.FormsWorkflow.com Defendant’s full name: -----------------------------------------------------------------------------------------------------------------------------------------------------Offense # Docket #: Arrest Tracking #: A.C.A. # of Offense: Name of Offense: Seriousness Level of Offense: Criminal History Score: Presumptive Sentence: Sentence is a departure from the sentencing grid. ___ Yes ___ No. Offense is a ___felony ___misdemeanor. Classification of offense: ___A ___B ___C ___D ___U ___Y Sentence imposed: ___ months. Suspended imposition of sentence: ___ months. Defendant was sentenced as an Habitual Offender under A.C.A. 5-4-501, Subsection ___(a) ___(b) ___(c) ___(d). Sentence was enhanced by ______ months pursuant to A.C.A. __________________________. Defendant ___attempted ___solicited ___conspired to commit the offense. Offense date: Number of counts: Defendant was on ___probation ___parole at time of conviction. Commitment on this offense is a result of the revocation of Defendant's probation or suspended imposition of sentence. ___ Yes ___ No. Victim of the offense was ___under ___over the age of 18 years. Defendant voluntarily, intelligently, and knowingly entered a ___ negotiated plea of guilty or nolo contendere. ___ plea directly to the court of guilty or nolo contendere. Defendant ___ entered a plea as shown above and was sentenced by a jury. ___ was found guilty of said charge(s) by the court, and sentenced by ___the court ___a jury. ___ was found guilty at a jury trial, and sentenced by ___the court ___a jury. -----------------------------------------------------------------------------------------------------------------------------------------------------Offense # Docket #: Arrest Tracking #: A.C.A. # of Offense: Name of Offense: Seriousness Level of Offense: Criminal History Score: Presumptive Sentence: Sentence is a departure from the sentencing grid. ___ Yes ___ No. Offense is a ___felony ___misdemeanor. Classification of offense: ___A ___B ___C ___D ___U ___Y Sentence imposed: ___ months. Suspended imposition of sentence: ___ months. Defendant was sentenced as an Habitual Offender under A.C.A. 5-4-501, Subsection ___(a) ___(b) ___(c) ___(d). Sentence was enhanced by ______ months pursuant to A.C.A. __________________________. Defendant ___attempted ___solicited ___conspired to commit the offense. Offense date: Number of counts: Defendant was on ___probation ___parole at time of conviction. Commitment on this offense is a result of the revocation of Defendant's probation or suspended imposition of sentence. ___ Yes ___ No. Victim of the offense was ___under ___over the age of 18 years. Defendant voluntarily, intelligently, and knowingly entered a ___ negotiated plea of guilty or nolo contendere. ___ plea directly to the court of guilty or nolo contendere. Defendant ___ entered a plea as shown above and was sentenced by a jury. ___ was found guilty of said charge(s) by the court, and sentenced by ___the court ___a jury. ___ was found guilty at a jury trial, and sentenced by ___the court ___a jury. ------------------------------------------------------------------------------------------------------------------------------------------------------ Page ___ of ___ American LegalNet, Inc. www.FormsWorkflow.com Defendant’s full name: -----------------------------------------------------------------------------------------------------------------------------------------------------Indicate which sentences are to run consecutively: Death Penalty: Execution Date: Total time to serve on all offenses listed above: ___________ months. Time is to be served at:___ Department of Correction ___ Regional Punishment Facility. Jail time credit:_______ days. Defendant was convicted of a target offense under the Community Punishment Act. The Court hereby orders that the Defendant be judicially transferred to the Department of Community Correction (D.C.C.). ___ Yes ___ No Failure to meet the criteria or violation of the rules of the D.C.C. could result in transfer to the A.D.C. Defendant was convicted of a “drug crime,” as defined in Act 1086 of 2007, and codified at A.C.A. 12-17-101 et seq. ___Yes ___No Fines $ C o u rt C o s ts $ Booking and Admin. Fee (A.C.A. 12-41-505) $ Drug Crime Special Assessment (A.C.A. 12-17-106) $ DNA Sample Fee (A.C.A. 12-12-1118) $ A judgment of restitution is hereby entered against the Defendant in the amount and terms as shown below: Amount $ ___ Due immediately ___ Installments of: Payment to be made to: If multiple beneficiaries, give names and show payment priority: Defendant has been adjudicated guilty of an offense requiring registration as a sex offender, and is ordered to complete the Sex Offender Registration Form: ___ Yes___ No. Defendant, who has been adjudicated guilty of an offense requiring registration as a sex offender, has been adjudicated guilty of a prior sex offense under a separate case number: Yes ____ No. If yes, list prior case number(s): _________________________ Defendant is alleged to be a Sexually Violent Predator, and is ordered to undergo an evaluation at a facility designated by the Department of Correction pursuant to A.C.A. 12-12-918: ___ Yes ___ No. Defendant has committed an aggravated sex offense, as defined in A.C.A. 12-12-903. ___ Yes ___ No. Defendant was adjudicated guilty of a felony offense, a misdemeanor sexual offense, or a repeat offense (as defined in A.C.A. 12-12-1103), and is ordered to have a DNA sample drawn at: ___ a D.C.C. facility ___ the A.D.C. or _____________ (other): ___ Yes ___ No. Defendant was informed of the right to appeal: ___ Yes ___ No. Appeal Bond: $ The County Sheriff is hereby ordered to transport the Defendant to ___the Arkansas Department of Correction ___ Regional Punishment Facility. -----------------------------------------------------------------------------------------------------------------------------------------------------The short report of circumstances attached hereto is approved. Date: Circuit Judge: Signature:_____________________ I certify this is a true and correct record of this Court. Date: Circuit Clerk/Deputy:____________________________________ (Seal) Form Revised 08/2007 Page ___ of ___ American LegalNet, Inc. www.FormsWorkflow.com