STATE OF WASHINGTON King County District Court East Division, Issaquah Courthouse No. , Statement of Defendant on Plea of Guilty Plaintiff vs. . Defendant. [ ] Count 1: ____________________ [ ] Count 2: ____________________ [ ] Count 3: ____________________ [ ] ____________________________ 1. My true name is ________________________________________. 2. My age is ___________________. 3. I went through the ___________________ grade. 4. I Have Been Informed and Fully Understand that: (a) I have the right to representation by a lawyer and that if I cannot afford to pay for a lawyer, one will be provided at no expense to me. (b) I am charged with: . The elements are: . 5. I Understand That I Have the Following Important Rights, and I Give Them All Up by Pleading Guilty: (a) The right to a speedy and public trial by an impartial jury in the county where the crime is alleged to have been committed; (b) The right to remain silent before and during trial, and the right to refuse to testify against myself; Statement of Defendant on Plea of Guilty - Page 1 of 4 CrRLJ-04.0200 (04/2007) - CrRLJ 4.2(g) American LegalNet, Inc. www.FormsWorkflow.com (c) (d) The right at trial to testify and to have witnesses testify for me. These witnesses can be made to appear at no expense to me; (e) I am presumed innocent unless the charge is proven beyond a reasonable doubt or I enter a plea of guilty; (f) 6. The right at trial to hear and question the witnesses who testify against me; The right to appeal a finding of guilt after a trial. In Considering the Consequences of my Guilty Plea, I Understand That: (a) The crime with which I am charged carries a maximum sentence of ________ days in jail and a $_____________ fine. (b) The prosecuting authority will make the following recommendation to the judge: . (c) The judge does not have to follow anyone’s recommendation as to sentence. The judge can give me any sentence up to the maximum authorized by law no matter what the prosecuting authority or anyone else recommends. (d) The judge may place me on probation for up to five years if I am sentenced under RCW 46.61.5055 or up to two years for all other offenses and impose conditions of probation. If the court orders me to appear at a hearing regarding my compliance with probation and I fail to attend the hearing, the term of probation will be tolled until I appear before the court on the record. (e) The judge may require me to pay costs, fees and assessments authorized by law. The judge may also order me to make restitution to any victims who lost money or property as a result of crimes I committed. The maximum amount of restitution is double the amount of the loss of all victims or double the amount of my gain. (f) If I am not a citizen of the United States, a plea of guilty to an offense punishable as a crime under state law is grounds for deportation, exclusion from admission to the United States, or denial of naturalization pursuant to the laws of the United States. Notification Relating to Specific Crimes. If any of the Following Paragraphs Apply, the Box Should Be Checked and the Paragraph Initialed by the Defendant. [ ] (g) The crime of _________________________________ has a mandatory minimum sentence of _____________________ days in jail and $____________ fine plus costs and assessments. The law does not allow any reduction of this sentence. [ ] (h) If this crime involves a sexual offense, prostitution, or a drug offense associated with hypodermic needles, I will be required to undergo testing for the human immunodeficiency (AIDS) virus. [ ] (i) This plea of guilty will result in suspension or revocation of my driving license or privilege by the Department of Licensing for a period of ________________. This period may not include suspension or revocation based on other matters. Statement of Defendant on Plea of Guilty - Page 2 of 4 CrRLJ-04.0200 (04/2007) - CrRLJ 4.2(g) American LegalNet, Inc. www.FormsWorkflow.com [ ] (j) I understand that I may not possess, own, or have under my control any firearm unless my right to do so is restored by a court of record and that I must immediately surrender any concealed pistol license. RCW 9.41.040. [ ] (k) If this crime involves a drug offense, my eligibility for state and federal education benefits will be affected. 20 U.S.C. § 1091(r). [ ] (l) If this case involves driving while under the influence of alcohol and/or being in actual physical control of a vehicle while under the influence of alcohol and/or drugs, I have been informed and understand that I will be subject to [ ] the penalties described in the “DUI” Attachment. OR [ ] these penalties: The mandatory minimum sentence of ______________ days in jail, _______________ days of electronic home monitoring and $_____________ monetary penalty. I may also be required to drive only motor vehicles equipped with an ignition interlock device as imposed by the Department of Licensing and/or the court. My driving privilege will be suspended or revoked by the Department of Licensing for the period of time stated in paragraph 6(i). In lieu of the minimum jail term, the judge may order me to serve ___________________ days in electronic home monitoring. If I do not have a dwelling, telephone service, or any other necessity to operate electronic home monitoring; if I live out of state; or if the judge determines I would violate the terms of electronic home monitoring, the judge may waive electronic home monitoring and impose an alternative sentence which may include additional jail time, work crew or work camp. [ ] (m) I understand that if this crime involves sexual misconduct with a minor in the second degree, communication with a minor for immoral purposes, or attempt, solicitation or conspiracy to commit a sex offense, or a kidnapping offense involving a minor, as defined in RCW 9A.44.130, I will be required to register with the county sheriff as described in the “Offender Registration” Attachment. [ ] (n) If this crime involves stalking, harassment or communication with a minor for immoral purposes, I will be required to have a biological sample collected for purposes of DNA identification analysis. RCW 43.43.754. [ ] (o) Travel Restrictions: I understand that I will be required to contact my probation officer, the probation director or designee, or the court if there is no probation department, to request permission to travel or transfer to another state if I am placed on probation for one year or more and this crime involves: (i) an offense in which a person has incurred direct or threatened physical or psychological harm; (ii) an offense that involves the use or possession of a firearm; (iii) a second or subsequent misdemeanor offense of driving while impaired by drugs or alcohol; (iv) a sexual offense that requires the offender to register as a sex offender in the sending state. I understand that I will be required to pay an application fee with my travel or transfer request. 7. I plead guilty to the crime(s) of as charged in the complaint(s) or citation(s) and notice. I have received a copy of that complaint or citation and notice. 8. I make this plea freely and voluntarily. Statement of Defendant on Plea of Guilty - Page 3 of 4 CrRLJ-04.0200 (04/2007) - CrRLJ 4.2(g) American LegalNet, Inc. www.FormsWorkflow.com 9. No one has threatened harm of any kind to me or to any other person to cause me to make this plea. 10. No person has made promises of any kind to cause me to enter this plea except as set forth in this statement. 11. The judge has asked me to state in my own words what I did that makes me guilty of this crime. This is my statement: . [ ] Instead of making a statement, I agree that the court may review the police reports and/or a statement of probable cause supplied by the prosecution to establish a factual basis for the plea. 12. My lawyer has explained to me, and we have fully discussed, all of the above paragraphs. I understand them all. I have been given a copy of this “Statement of Defendant on Plea of Guilty.” I have no further questions to ask the judge. Date: Defendant I have read and discussed this statement with the defendant and believe that the defendant is competent and fully understands the statement. Prosecuting Authority Type or Print Name Defendant's Lawyer WSBA No. Type or Print Name WSBA No. The foregoing statement was signed by the defendant in open court in the presence of the defendant’s lawyer and the undersigned judge. The defendant asserted that (check the appropriate box): [ ] (a) The defendant had previously read; or [ ] (b) The defendant’s lawyer had previously read to him or her; or [ ] (c) An interpreter had previously read to the defendant the entire statement above and that the defendant understood it in full. I find the defendant’s plea of guilty to be knowingly, intelligently and voluntarily made. Defendant understands the charges and the consequences of the plea. There is a factual basis for the plea. The defendant is guilty as charged. Dated: Judge Statement of Defendant on Plea of Guilty - Page 4 of 4 CrRLJ-04.0200 (04/2007) - CrRLJ 4.2(g) American LegalNet, Inc. www.FormsWorkflow.com Interpreter’s Declaration (If required, attach to Statement of Defendant on Plea of Guilty.) I am a certified interpreter or have been found otherwise qualified by the court to interpret in the _________________________________ language, which the defendant understands, and I have translated for the defendant from English into that language. (Identify document being translated) The defendant has acknowledged his or her understanding of both the translation and the subject matter of this document. I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Dated: __________________________________ ____________________________________ Interpreter ____________________________________ Type or Print Name Location: . American LegalNet, Inc. www.FormsWorkflow.com