4 Rule 2.76 — Form 2: Consent to Forfeiture of Collateral as Disposition of Misdemeanor. February 2002 State of Iowa County of ___________________________ Criminal Case No. _____________________ I, the undersigned, agree to have the amount of $________________ forfeited as a fine and my case terminated. I do this with the following understanding: 1. I have been charged with the offense of _____________________ (here name the offense and Code or ordinance section). 2. I understand my rights, including my right to trial before the court on such charge, and voluntarily waive same, understanding that forfeiture of the aforesaid amount terminates my right to a trial and constitutes a conviction of the offense charged. __________________________________________________ (Signature of defendant) American LegalNet, Inc. www.FormsWorkflow.com