IN THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF OKLAHOMA UNITED STATES OF AMERICA, Plaintiff, v. Defendant. ) ) ) ) ,) ) ) CASE NO. PETITION TO ENTER PLEA OF GUILTY The defendant states to the Court that the defendant wants to enter a plea of GUILTY to the following counts of the Indictment or Information: In connection with this plea of GUILTY, I, , the defendant in this case, inform the Court, under penalty of perjury, that I have discussed these matters with my attorney and the answers to the following questions are true and correct to the best of my knowledge and belief. A. BACKGROUND QUESTIONS Before the Court can accept your plea of guilty, it is necessary that the Court has certain background information about you and this case. The questions in this section are asked for this purpose. 1. (a) (b) 2. What is your name? What is your age? Are you currently employed? Yes No If yes, what is the name, address and telephone number of your employer? 3. How much education have you had? OKWD Plea Petition (9/12) American LegalNet, Inc. www.FormsWorkFlow.com 4. Have you ever received medical care or treatment for drug addiction and/or alcohol abuse? Yes No [If so, prior to the hearing on the Petition to Enter Plea of Guilty, counsel for defendant shall submit to the judge's orders mailbox a list of the dates, places, and types of treatment received by defendant.] 5. Have you ever received medical care or treatment for a mental or emotional condition? Yes No [If so, prior to the hearing on the Petition to Enter Plea of Guilty, counsel for defendant shall submit to the judge's orders mailbox a list of the dates, places, and types of treatment received by defendant.] 6. (a) Have you consumed any drug, alcohol or medication that is now impairing your ability to think clearly or to understand and answer the questions in this Petition to Enter Plea of Guilty? Yes No Are there any medications prescribed for you that you are not now taking as directed? Yes No If yes, does the fact that you are not taking the medication as directed impair your ability to think clearly or to understand and answer the questions in this Petition to Enter Plea of Guilty? Yes No (b) 7. If an attorney is now representing you in this case, what is your attorney's name? 8. If you have an attorney, have you had enough time to talk with your attorney about your case? Yes No If you have an attorney, have you told your attorney everything you know about your case? Yes No If you have an attorney, are you satisfied with the services your attorney has provided for you? Yes No Do you understand the charge(s) against you? Yes No 9. 10. 11. OKWD Plea Petition (9/12) Page 2 of 13 American LegalNet, Inc. www.FormsWorkFlow.com B. CONSTITUTIONAL RIGHTS - WAIVERS Before the Court can accept your plea of guilty, it is important that you understand that you will be giving up many valuable constitutional rights by entering a plea of guilty. The questions in this section are designed to inform you of those rights. 12. Do you understand you have a right to plead NOT GUILTY to every charge filed against you? Yes No Do you understand if you plead NOT GUILTY you have the following constitutional rights: (a) the right to a speedy and public trial by jury? Yes No the right to counsel at all stages of the proceedings, and that if you cannot afford to pay a lawyer, one will be appointed to represent you? Yes No the right to see and hear all witnesses called to testify against you and the right to cross-examine them? Yes No the right to use the subpoena power of the Court to compel the attendance of witnesses at trial and the production of other forms of evidence? Yes No the right not to be compelled to incriminate yourself by taking the witness stand; and that if you do not take the witness stand, no inference of guilt may be drawn from your failure to do so? Yes No the right to be presumed innocent until the government has proved you guilty beyond a reasonable doubt by the unanimous agreement of all twelve of the jury members? Yes No 13. (b) (c) (d) (e) (f) 14. Do you understand if you plead GUILTY you will be found guilty without a trial and you will have given up all of the above rights, except the right to counsel? Yes No OKWD Plea Petition (9/12) Page 3 of 13 American LegalNet, Inc. www.FormsWorkFlow.com 15. Do you understand if you plead GUILTY to a felony offense this may deprive you of valuable civil rights including the right to vote, the right to hold public office, the right to serve on a jury, the right to possess any kind of firearm, destructive device or ammunition, and may make you ineligible for certain government benefits? Yes No Not Applicable ___ If you are not a citizen of the United States, pleading guilty may affect your immigration status. Pleading guilty may result in your deportation or removal from the United States, may prevent you from ever lawfully reentering or remaining in the United States, and may result in the denial of naturalization. Deportation is mandatory for certain offenses, including most crimes involving controlled substances. You may be deported or removed from the United States even if you are a legal resident and even if you have legally lived in the United States for many years. Do you understand? Yes No Not Applicable SENTENCING - GENERAL 16. C. Before the Court can accept your plea of guilty, it is important that you understand certain aspects of the sentencing process. The questions in this section are designed for that purpose. 17. Do you realize if you plead GUILTY the maximum statutory sentence the judge may impose remains the same as if you had pled NOT GUILTY and had been convicted by a jury? Yes No Do you know the sentence you will receive is solely a matter for the judge to decide? Yes No (a) What is the maximum sentence the law provides for the offense(s) to which you want to plead GUILTY? 18. 19. OKWD Plea Petition (9/12) Page 4 of 13 American LegalNet, Inc. www.FormsWorkFlow.com (b) Is there a minimum mandatory sentence the law provides for the offense(s) to which you want to plead GUILTY? Yes No If yes, what is it? (c) For certain offenses a term of supervised release must be imposed to be served after the person is released from a term of imprisonment. Is there a mandatory term of supervised release for the offense(s) to which you want to plead GUILTY? Yes No If yes, what is the maximum mandatory term? For all other offenses, the judge may, in the judge's discr