WAIVER OF CHILD/PARENT STATEMENT OF RESPONSIBILITY JD-JM-29 Rev. 6-96 CGS 46b-135 to 137, 138a Pr. Bk. Secs. 1025.1, 1048.1 STATE OF CONNECTICUT SUPERIOR COURT JUVENILE MATTERS ADDRESS OF COURT DOCKET NO. NAME AND ADDRESS OF CHILD BIRTHDATE NAME AND ADDRESS OF PARENT(S) OR GUARDIAN WAIVER OF CHILD I, , in the presence of my (parent(s)/guardian), and having been informed in (his/her/their) presence of my right 1) to counsel, and the Court's obligation to provide counsel if I cannot afford it; 2) to remain silent because my statement may later be used against me; and 3) to be fully informed as to my claimed delinquent behavior as set forth in the Notice to Appear or summons, dated do hereby for the purpose of this proceeding waive my right to counsel and to remain silent. SIGNATURE OF CHILD SIGNATURE OF PARENT OR GUARDIAN DATE WAIVER OF PARENT OR GUARDIAN I, , parent/guardian of have been informed of my right to counsel and the Court's obligation to provide counsel if I cannot afford it, and my further right to refuse to testify against said child except that a parent or guardian who has received personal violence from said child, may upon trial for such personal violence be compelled to testify. The parent or guardian may refuse to testify if the testimony might tend to incriminate the parent or guardian. I do hereby for the purpose of this proceeding waive my right to counsel and to remain silent. SIGNATURE OF PARENT OR GUARDIAN SIGNATURE OF WITNESS DATE STATEMENT OF RESPONSIBILITY I, , in the presence of my (parent)(parents)(counsel) admit that I am responsible for the following act(s): SIGNATURE OF CHILD SIGNATURE OF PARENT OR GUARDIAN DATE American LegalNet, Inc. www.FormsWorkflow.com