DC-21 (revised October 2017) Page 1 of 2 STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DISTRICT COURT REQUEST TO ENTER PLEA OF NOLO CONTENDERE OR GUILTY State of Rhode Island v. Defendant Case Number CHARGES I, , do hereby certify that the judicial officer of the District Court has advised me of my rights as follow: 1. That I am charged with the above-named crime(s). 2. That I have a right to remain silent and that if I make a statement it may be used against me. 3. That I have reasonable time to consult with an attorney and be admitted to bail. 4. That I have a right to be represented by an attorney of my own choice at my own expense and if I cannot afford to have an attorney the court will refer me to a public defender or other assigned attorney at no cost to me. 5. That I have a right to a trial by jury in the first instance but I may waive that right and have a trial in the District Court and if found guilty I am entitled to appeal that judgment to the Superior Court and may have a de novo trial before a jury. I WISH TO PROCEED WITHOUT AN ATTORNEY REPRESENTING ME KNOWING THE ABOVE RIGHTS. I wish to enter a plea of guilty or nolo contendere to the above charge(s). When I plead I know that I am admitting sufficient facts to substantiate the charge(s) listed above. And, by pleading I know that I am giving up and waiving the following rights. 1. My right to a trial by jury or by a judge, sitting without a jury. 2. My right to have the city/state prove each and every element of the charge(s) against me by evidence and proof beyond a reasonable doubt. 3. My right to the presumption of innocence. 4. My right against self-incrimination. 5. My right to confront and cross-examine the witnesses against me. 6. My right to present evidence and witnesses on my behalf and to testify in my own defense if I choose to do so. GENERALLY I understand that certain statues provide that upon a second conviction the penalties imposed will increase and may result in a mandatory jail sentence being imposed. American LegalNet, Inc. www.FormsWorkFlow.com DC-21 (revised October 2017) Page 2 of 2 STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DISTRICT COURT EFFECTS OF CRIMINAL CONVICTION If I violate the terms and conditions of my probation, I may be held without bail and sentenced to jail upon the judge being reasonably satisfied of the violation. DOMESTIC ABUSE CASES I understand that by entering a plea of nolo contendere, resulting in a filing, probation, or conviction of a domestic violence offense as enumerated in G.L. 1956 247 12-29-2, that, in addition to any other sentence or penalty, I will be prohibited from purchasing, owning, carrying, transporting, or having possession of any firearm pursuant to G.L. 1956 247 11-47-5 and will be subject to surrendering all firearms in my ownership, possession, care, custody, or control pursuant to G.L. 1956 247 11-47-5.4. DRUNK DRIVING CASES I understand that upon a second conviction and subsequent other convictions within a five-year period, the penalties for drunk driving will increase and will include mandatory jail sentences. I understand that if my license has been suspended for certain reasons, including drunk driving, refusing to submit to a chemical test, or reckless driving, the sentence for the first conviction for driving on a suspended license will include a mandatory jail sentence. LICENSE SUSPENSION CASES I understand that this section provides that first and second offenses are considered a civil violation. A third and subsequent offense will result in a misdemeanor and penalties imposed will increase and also may result in a jail sentence. IMMIGRATION CONSEQUENCES I know that if I am not a citizen of the United States, a plea of guilty or nolo contendere may have immigration consequences, including deportation, exclusion of admission to the United States, or denial of naturalization pursuant to the laws of the United States. I acknowledge that I have read and reviewed the entire contents of this form, d I have no questions as to what the form states and means, and I understand the form completely. I wish to proceed without a lawyer representing me knowing the above rights. Signature of the Defendant Entered as an Order of the court on Judicial Officer/Clerk Date American LegalNet, Inc. www.FormsWorkFlow.com