COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : STATE OF NORTH CAROLINA No. : Plaintiff(s) STATE VERSUS -against- Calendar No. : County Name Of Defendant Index File No. JUDICIAL SUBPOENA In The General Court Of Justice District Superior Court Division : :WAIVER : OF COUNSEL G.S. 7A-457; 15A-1242 Additional File No.(s) And/Or Offense(s) Defendant(s) : ...................................................... THE PEOPLE OF THE STATE OF NEW YORK ACKNOWLEDGMENT OF RIGHTS AND WAIVER TO As the undersigned party in this action, I freely and voluntarily declare that I have been fully informed of the charges against me, the nature of and the statutory punishment for each such charge, and the nature of the proceedings against me; that I have been advised of my right to have counsel assigned to assist me and my right to have the assistance of counsel in defending against these charges or in handling these proceedings, and that I fully understand and appreciate the consequences of my decision to waive the right to assigned counsel and the right to assistance of counsel. GREETINGS: I freely, voluntarily and knowingly declare that: all business and excuses being laid aside, you and each of you attend before WE COMMAND YOU, that , the Honorable at the Court located at County of 1. I waive my right to assigned counsel and that I, hereby, expressly waive that right. in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, toassistance of counsel which a witness mythis action on the part of the my right to the testify and give evidence as includes in right to assigned counsel and 2. I waive my right to all (check only one) assistance of counsel. In all respects, I desire to appear in my own behalf, which I understand I have the right to do. Date Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Signature Signature Of Defendant result of your failure to comply. SWORN AND SUBSCRIBED TO BEFORE ME Date Deputy CSC Court in Clerk Assistant CSCHonorable Of Superior Court Witness, County, , one of the Justices of the day of , JUDGE CERTIFICATE OF20 I certify that the above named defendant has been fully informed in open court of the charges against him/her, the nature of and the statutory punishment for each charge, and the nature of the proceeding against the defendant and his/her right to have counsel assigned by the court and his/her right to have the assistance ofmust sign above and type name below)in this (Attorney counsel to represent him/her action; that the defendant comprehends the nature of the charges and proceedings and the range of punishments; that he/she understands and appreciates the consequences of his/her decision and that the defendant has voluntarily, knowingly and intelligently elected in open court to be tried in this action: Attorney(s) for (check only one) 1. without the assignment of counsel. 2. without the assistance of counsel, which includes the right to assigned counsel and the right to assistance of counsel. Office and P.O. Address Date NOTE: For a waiver of assigned counsel only, both blocks numbered "1" must be checked. For a waiver of all assistance of counsel, both blocks numbered "2" must be checked. AOC-CR-227, Rev. 6/97 1997 Administrative Office of the Courts I Signature Of Judge Telephone No.: Facsimile No.: Name Of Judge (Type Or Print) E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com