THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) WAIVER OF COUNSEL I, have been charged with before Superior Court. I have had explained to me at arraignment (my first court hearing) my right to be represented by an attorney. I understand that if I an unable to afford an attorney, the Court will appoint one to represent me. I have had the charge or charges against me fully explained. I understand that the charge or charges against me is/are FELONIES. Those penalties have been fully explained to me. I have had the charge or charges against me fully explained. I understand that the charge or charges are MISDEMEANORS. If the court finds that I have committed the above offense(s), penalties may include: supervision by probation; payment of a fine; restitution; or incarceration in the county house of corrections. I understand that any proposed plea or negotiated sentence is subject to the approval of the Judge and the Judge may reject any proposed plea agreement. I understand what I am doing. I DO NOT want an attorney and hereby waive (give up) my right to have an attorney represent me. of , Date Signature of Defendant The undersigned Justice, having asked the defendant if s/he understands the charge(s) against him/her and the possible penalties which the court may order, is satisfied that s/he fully understands his/her right to have an attorney represent him/her and, if indigent, to have an attorney appointed by the court. Based upon this inquiry, the Court finds that the defendant has the mental capacity to evaluate his/her right to an attorney, the risks associated in proceeding without an attorney, the possible penalties upon conviction and finds that the defendant does knowingly and voluntarily waive that right. Date Signature of Justice NHJB-2044-S (03/27/2007) Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com