DNJ-R 11-003 (06/05) UNITED STATES DISTR ICT COURT DISTRICT OF NEW JERSEY UNITED STATES OF AMERICA Mag./Crim. No. ___________ APPLICATION FOR PERMISSION v. TO ENTER PLEA OF GUIL TY (Defendant with Counsel) he reby certifies as follows: (Defendants Name) 1. My full name is _____________________________________ and I request that all proceedings against me be held in that name. 2. I understand that the Constitution and laws of the United States guarantee me the right to be represented by a lawyer at every stage in these proceedings, including any trial on these charges, and that if I cannot afford to hire a lawyer, the Court will provide one for me. 3. I have a lawyer who is representing me in this proceeding. My lawyers name is _________________________________ . I am satisfied that I have had enough time to discuss this matter with my lawyer. 4. English [IS] [IS NOT] my native language. My formal education stopped after [grade] . I am presently [UNEMPLOYED] [EMPL OYED] as a ______________________________________ (occupation). 5. I have taken [NO] [THE FOLL OWING] drugs or medication within the past seventy-two hours: . 6. I [HAVE] [HAVE NEVER] been a patient in a mental hospital or institution. I [DO] [DO NOT] believe that at the present time I am mentally ill or mentally incompetent in any respect. 7. I received a copy of the [COMPLAINT] [INDICTMENT] [INFORMAT ION] before being called upon to plead. I have read and discussed it with my lawyer. I understand that the substance of the charge(s) against me is that I: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ [add separate sheets if necessary] American LegalNet, Inc. www.USCourtForms.com>>>> 2WAIVER OF INDICTMENT (IF APPLICABL E) 8. My lawyer has explained to me that I have a constitutional right to be charged by an indictment of a grand jury but that I can waive that right and consent to being charged through a criminal Information filed by the United States Attorney. 9. I understand that unless I waive indictment I may not be charged with a felony unless a grand jury finds by return of an indictment that there is probable cause to believe that a crime has been committed and that I committed it. 10. I also understand that if I do not waive indictment, the government may present the case to the grand jury and request the grand jury to indict me. 11. I understand that a grand jury is composed of at least 16 and not more than 23 persons, that at least 12 grand jurors must find that there is probable cause to believe that I committed the crime. I also understand that the grand jury may or may not indict me. 12. I further understand that by waiving indictment by the grand jury, the case will proceed against me on the United States Attorneys Information as though I had been indicted. 13. My attorney has discussed the nature of the charges(s) against me and waiving my right to indictment thereon by grand jury, I fully understand those rights, and I wish to waive indictment by grand jury. 14. My decision to waive indictment by grand jury is made knowingly and voluntarily, and no threats or promises have been made to induce me to waive indictment. THE GUIL TY PLEA 15. I have told my lawyer all the facts and circumstances known to me about the charge(s) set forth in the [COMPL AINT] [INDICTMENT] [INFORMATI ON]. 16. I am satisfied that my lawyer understands the information which I have provided, and that my lawyer has counseled and advised me on the nature of each charge and on all possible defenses that I might have in this case. 17. In addition, my lawyer has explained to me, and I understand, that if I entered a plea of NOT GUIL TY (or persisted in my plea of NOT GUIL TY), under the Constitution and laws of the United States I would be entitled to a speedy and public trial by a jury of twelve persons on the charge(s) contained in this [COMPLAINT] [INDICTMENT] [INFORM ATION]. 18. My lawyer has explained to me, and I understand, that at such a trial the jury would be told by the judge that I am presumed to be innocent, and that the Government would be 2 American LegalNet, Inc. www.USCourtForms.com>>>> 3 required to prove me guilty of the charge(s) against me beyond a reasonable doubt. I understand that I would not have to prove that I am innocent, and that I could not be convicted unless all twelve jurors voted unanimously for conviction. 19. My lawyer has explained to me, and I understand, that if I went to trial on these charge(s), the Government would have to produce in open court the witnesses against me, and that my lawyer could confront and cross-examine them and object to evidence offered by the Government. 20. My lawyer has further explained to me, and I understand, that I have the right to produce witnesses and could offer evidence in my defense at a trial on these charge(s), and that I would have the right, if I so chose, to testify on my own behalf at that trial; but if I chose not to testify, the jury could draw no suggestion or inference of guilt from that fact. 21. My lawyer has explained to me, and I understand, that if I plead GUIL TY to any charge(s) in this [COMPLAINT] [INDICTMENT] [ INFORMATION] and the judge accepts my plea, I WA IVE MY RIGHT TO TR IAL AND THE OTHER RIGHTS SET FORTH IN PARAGRA PHS 17, 18, 19 and 20 ABOVE. I am aware and understand that if my GUIL TY plea is accepted, there will be no trial and a judgment of GUIL TY will be entered after which, the judge, upon consideration of my presentence report, will impose punishment upon me. I understand that if I plead GUIL TY, the judge may impose the same punishment as if I had pleaded "not guilty", went to trial and was convicted by a jury. 22. My lawyer has also explained to me, and I understand, that if I plead GUIL TY, I WAIVE MY RIGHT NOT TO INCRIMINATE MYSEL F. I understand that the judge will ask me what I did and I will have to acknowledge my guilt as charged by setting forth my actions so that the judge is satisfied that I am, indeed, guilty. I understand that any statements I make at the time I plead GUIL TY, if untrue and made under oath, can be the basis of a perjury prosecution against me. SENTENCING ISSUES 23. My lawyer has informed me, and I understand, that the maximum punishment which the law provides for the offense(s) charged in this [COMPLAINT] [INDICTMENT