DEFENSE OF INDIGENTS ACT FORM NO. 1 A STATEMENT OF THE RIGHTS OF AN ACCUSED You have been arrested and charged with the crime of ____________________________ ________________________________________________________________________ You are advised: (a) You have a right to employ counsel to represent you. (b) In the even you are financially unable to employ counsel, the State will provide you with counsel by appointment or with the services of the Public Defender of the County. If you desire the State to provide you with counsel, you may make application for counsel on a form which I will give to you. The form has been read to the accused,_______________________________________, in my presence, at ______ oclock p.m. a.m., this ______ day of _________________, ___________________________________ C lerk of Court o r other Officer (if the accused cannot employ counsel and does not wish the State to provide him with counsel at this time, he shall be asked to execute the following statement.) WAIVER OF RIGHT TO HAVE APPOINTED COUNSEL OR SERVICES OF PUBLIC DEFENDER The undersigned certifies that he has been informed of the charges against him and the nature thereof, and that he is unable to employ counsel. However, the undersigned now state that he does not at this time desire to apply for the appointment of counsel or for the services of the Public Defender, and expressly waives his desire to services of counsel provided by the State at this time, which he understand he has a right to do. ____________________________________ D efendant Executed before me this __________day of ____________________________, _______. ____________________________________ Signature of Clerk of Court or Officer