UNITED STATES DISTRICT COURT FOR THE DISTRICT OF RHODE ISLAND UNITED STATES OF AMERICA v. Criminal No. CERTIFICATION OF DEFENDANT'S MEDICATION DIRECTIONS: Counsel should complete and sign either Part 1 or Part 2, as appropriate. PART 1 As counsel for defendant _____________________, I hereby certify that I have conferred with my client and he or she has advised me that he or she is not taking any form of medication. Date:________________________ _____________________________ Attorney Signature ---------------------------------------------------------------------------------------------------------------------PART 2 As counsel for defendant __________________________________________________, I hereby certify that I have conferred with my client and determined that he or she is taking the following medication(s) in the indicated dosages: Medication Dosage _______________________ ____________ _______________________ ____________ _______________________ ____________ Furthermore, I certify that I have conferred with _________________________________ _____________________________________________________________________________, defendant’s physician, who has stated that the above medication(s), when taken in the dosage(s) indicated, do not impair the defendant's ability to understand the nature of the charges against him, the terms of the Plea Agreement between the defendant and the government, or the consequences of pleading guilty to those charges. Date:_________________________ ______________________________ Attorney Signature American LegalNet, Inc. www.USCourtForms.com