IN THE CIRCUIT COURT FOR THE FOURTH JUDICIAL CIRCUIT MONTGOMERY COUNTY, ILLINOIS THE PEOPLE OF THE STATE OF ILLINOIS, vs. ) ) ) ) ____________________________________________ ____ - TR - __________ JURY WAIVER, PLEA OF GUILTY, AND APPLICATION FOR COURT SUPERVISION Please answer the following questions: 1. In any state or country, have you ever been convicted or received court supervision for the following offenses: OFFENSE Driving Under the Influence Reckless Homicide Driving while Revoked or Suspended Fleeing or Attempting to Elude Police NO YES YEAR 2. In any state or country, has your driver’s license (or the right to obtain a license) ever been suspended or revoked? If yes, please state the date, location and reason for the suspension or revocation. YES NO DATE LOCATION REASON 3. Within the last twelve months, have you been convicted OR have you received court supervision in another traffic case anywhere? If yes, please provide the date, location and the type of offense. YES NO DATE LOCATION TYPE OF OFFENSE Conv Super 4. Other than your Montgomery County ticket, do you have a traffic citation pending in another county, state or country? YES NO DATE LOCATION TYPE OF OFFENSE 5. Are you currently on court supervision for other traffic OR criminal offenses? YES NO DATE LOCATION TYPE OF OFFENSE 6. You have the following rights in this case: • the right to a trial, by judge or jury; • you are presumed innocent, the State must prove you guilty beyond a reasonable doubt; • the right to present a defense and summon or subpoena witnesses on your behalf; • the right to confront and cross-examine your accusers; • the right to testify or remain silent; your silence may not be used as evidence against you; • the right to be represented by an attorney YES, I understand these rights, but wish to waive them and plead guilty to the charge against me, and request that I be placed on court supervision. NO, I do not understand the rights listed above. page 1 of 2 REVISED 3/95 American LegalNet, Inc. www.USCourtForms.com 7. Do you understand that should you violate your supervision, the State may file a petition to revoke the supervision. If your supervision is revoked, you may be re-sentenced on the original charge. YES, I understand. NO, I do not understand. DEFENDANT’S FULL NAME: __________________________________________________________________ DEFENDANT’S ADDRESS: __________________________________________________________________ street apt. # __________________________________________________________________ city state zip DRIVER’S LICENSE: __________________________________________________________________ number issuing state UNDER PENALTIES OF PERJURY AS PROVIDED BY LAW PURSUANT TO SECTION 1-109 OF THE ILLINOIS CODE OF CIVIL PROCEDURE, THE UNDERSIGNED CERTIFIES THAT THE STATEMENTS SET FORTH IN THIS INSTRUMENT ARE TRUE AND CORRECT: Date:____________ ______________________________________________ DEFENDANT’S SIGNATURE APPROVED AS TO FORM AND CONTENT: ______________________________________________________ ASSISTANT STATE’S ATTORNEY DATE -------------------------------------DO NOT WRITE BELOW THIS LINE------------------------------------ SUPERVISION ORDER The defendant having entered a plea of guilty to the petty offense charged herein, and the Court being of the opinion that: 1. The offender is not likely to commit further crimes; 2. The defendant and the public would best be served if the defendant were not to receive a criminal record; and 3. An Order of Supervision is more appropriate than a sentence otherwise permitted under the Criminal Code. IT IS THEREFORE ORDERED that Judgment is stayed and the defendant is hereby placed on Supervision for a period of _______days/months during which time the defendant shall keep the following conditions: 1. That the defendant shall pay a fine and costs totaling $ ______________instanter made payable to MONTGOMERY COUNTY CIRCUIT CLERK. PLEASE DO NOT SEND ANY PERSONAL CHECKS. 2. That the defendant shall not violate any law or ordinance of the State of Illinois, any political subdivision, or any other state. 3. That the defendant shall keep the clerk of the Court advised of his or her current residence address and shall report to this Court whenever notice is sent by U.S. Mail to the defendant’s last reported address. ENTER: ______________________ _________________________________ JUDGE page 2 of 2 American LegalNet, Inc. www.USCourtForms.com