IN THE ______ JUDICIAL CIRCUIT COURT, _______________________________, MISSOURI Judge or Division: Case Number: (Date File Stamp) Waiver of Right to Auxiliary Aids / Interpretive Services/Translator Services by the Hearing Impaired or Limited English Proficiency (LEP) Person Pursuant to section 476.760.3, RSMo, I knowingly and voluntarily waive the right to auxiliary aids and services, which are available under the provisions of section 476.750(2), RSMo. ____________________________ Date _______________________________________ Person Waiving Right _______________________________________ Counsel to the Hearing Impaired Person (if any) _______________________________________ Designated Responsible Authority (if no counsel is used) Pursuant to section 476.803, RSMo, I knowingly, intelligently and voluntarily waive the right to a qualified interpreter or translator. I have been advised of the consequences of this decision and understand I can retract this waiver at anytime and a qualified interpreter shall be appointed for me. ____________________________ Date _______________________________________ Person Waiving Right _______________________________________ Counsel to the Limited English Proficiency Person (if any) OSCA (04-11) GN20 1 of 1 Sections 476.750, 476.760, 476.803, RSMo American LegalNet, Inc. www.FormsWorkFlow.com