STATE OF NORTH CAROLINA County Name Of Juvenile Date Of Birth Name And Address Of Parent File No. In The General Court Of Justice District Court Division IN THE MATTER OF: Age WAIVER OF PARENT'S RIGHT TO COUNSEL ABUSE/NEGLECT/DEPENDENCY TERMINATION OF PARENTAL RIGHTS G.S. 7B-602, -1101.1 I am the parent of the juvenile named above. I have been told that I have the right to have a lawyer represent me. I have been told of my right to have a lawyer appointed by the Court if I cannot afford to hire one. With full knowledge of these rights, I knowingly, willingly, and understandingly choose as follows: (check only one) 1. I do not want a court-appointed lawyer. I will hire my own lawyer at my own cost. 2. I do not want the assistance of any lawyer. I understand that I have the right to represent myself, and that is what I intend to do. Date Name Of Parent (Type Or Print) Signature Of Parent FINDINGS OF FACT NOTE TO JUDGE: G.S. 7B-602(a1) and G.S. 7B-1101.1(a1) require the court to examine the parent and make findings of fact sufficient to show that the parent's waiver is knowing and voluntary. CONCLUSIONS OF LAW The parent's waiver is knowing and voluntary. The parent's waiver is not knowing and voluntary. ORDER Therefore, the parent may proceed without appointed counsel. may proceed without the assistance of counsel. Date Name Of District Court Judge (Type Or Print) Signature Of District Court Judge AOC-J-143, Rev. 10/13 (Replaces J-203) � 2013 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com