Va. R. Sup. Ct. Form 6
VIRGINIA:
IN THE CIRCUIT COURT FOR THE
____________________________________
COMMONWEALTH OF VIRGINIA
v.
Case No.: _____________________
_____________________________________
WAIVER OF RIGHTS FORM (Rule 3A:8)
Answer "Yes" or "No" or "N/A" where indicated
1. What is your full name?
___________________________________________________________________
2. What is your date of birth?
___________________________________________________________________
3. How much education do you have?
___________________________________________________________________
4. Can you read and write the English language?___________________________________________________________________
If not, is this form being read to you and by whom?
___________________________________________________________________
5. Have you consumed any alcohol, drugs or medication that might affect your ability to understand these proceedings or answer these questions truthfully?
___________________________________________________________________
6. Are you the person named in the indictment, information or warrant with the commission of the offense(s) of _____________________________________ ?
7. Has your attorney reviewed with you the nature of the charge(s) pending against you?
___________________________________________________________________
8. Do you fully understand those charges(s), as explained to you by your attorney?
___________________________________________________________________
9. Did you have sufficient time to discuss with your attorney the facts of the case and the legal elements of the charge(s)?
___________________________________________________________________
10. Do you understand what facts the Commonwealth would be required to prove beyond a reasonable doubt in open court before this court could find you guilty of the charge(s)?
___________________________________________________________________
11. Have you had sufficient time to discuss with your attorney any defenses that you might have to the charge(s)? _____
12. Have you discussed with your attorney your right to plead guilty, no contest or not guilty?
___________________________________________________________________
13. Has anyone intimidated you, forced you, offered you leniency (beyond what may be contained in your plea agreement, if applicable) or in any way influenced you to plead guilty/no contest?
___________________________________________________________________
14. Has your attorney made any promises to you with respect to your plea(s)?
___________________________________________________________________
15. Did you decide for yourself that you would offer a plea of guilty/no contest to the charge(s)?
___________________________________________________________________
16. Are you pleading guilty/no contest because you are in fact guilty of the offense(s) for which you are charged? ______
Or, are you pleading guilty/no contest because after discussing this matter with your attorney you believe it will be in your best interests to do so? _______
17. Is your plea of guilty/no contest made freely, voluntarily, and without force, intimidation or promises? _______________________
18. Do you understand that by pleading guilty/no contest you give up basic rights that are guaranteed to you by the Constitution of the United States and the Constitution of Virginia? _____
19. Do you understand that by pleading guilty/no contest you give up the following rights:
(a) To have your case tried by a jury? _____
(b) Not to incriminate yourself (by waiving this right, you can be forced to make statements against your interest)? _____
(c) To confront and cross-examine each witness who may be called by the Commonwealth to offer testimony against you? _____
(d) To present a defense in your own behalf? _____
20. Do you fully understand that by pleading guilty/no contest you may waive any grounds you have to appeal your case? _____
21. Are you currently in prison, on parole or probation or under a suspended sentence? _____
22. Do you understand that pleading guilty/no contest may affect your right to parole, or cause revocation of your parole, probation or suspended sentence? _____
23. Does that affect your decision to plead guilty/no contest? _____
24. Has anyone associated with your arrest or prosecution, such as the police, Commonwealth's Attorney or any other person forced, threatened or coerced you to plead guilty/no contest? _____
25. Outside of the terms and conditions as set forth in any Plea Agreement that you have entered into with the Commonwealth, has any person made any other promises to you in writing or orally to induce you to plead guilty/no contest? ___________
26. Have you entered into a Plea Agreement with the Commonwealth in this case? ___________
27. Did you read this Plea Agreement that you have offered to the Court in this case? ___________
28. Do you fully understand the content and meaning of the Plea Agreement? ___________
29. Did you sign this Plea Agreement in the presence of your attorney? ___________
30. Do the terms of this Plea Agreement contain the full and complete agreement entered into among you, your lawyer and the Commonwealth? ___________
31. Are there any other written or oral agreements that are not reflected in this Plea Agreement? ___________
32. Do you understand that, if the Court accepts the Plea Agreement, everyone who has signed the document will be bound by its content? ___________
33. Do you believe it is in your best interest and to your benefit to offer the Plea Agreement to the Court? ___________
34. To be asked if the Commonwealth has agreed that a specific sentence is appropriate:
(a) Do you understand that the Court may accept, reject or defer accepting or rejecting the Plea Agreement until there has been an opportunity to consider a presentence report? ___________
(b) Do you understand that, if the Court rejects the Plea Agreement, you would be permitted to withdraw your plea of guilty/no contest and have your case heard by a jury or another Judge? ___________
(c) Do you understand that if the Court rejects the Plea Agreement and you persist in your plea of guilty/no contest, the Court would not be bound to honor any of the terms or conditions set forth in the Plea Agreement? _____________________
35. To be asked if the Commonwealth merely recommends, or agrees not to oppose a request for, a specific sentence:
(a) Do you understand that this agreement only provides for the Commonwealth to make a recommendation or to agree not to oppose a request for a particular sentence, that this recommendation or request is not binding on the Court, and if the Court does not accept the recommendation or does not go along with the request, you have no right to withdraw your plea of guilty/no contest unless the Commonwealth fails to perform its part of the agreement? ___________
(b) Do you also understand that the sentence the Court imposes may be more severe than the sentence recommended or requested? ___________
36. Do you understand that the maximum punishment for the crime(s) to which you are pleading guilty/no contest is years imprisonment and $ _ in fines, plus all court costs? ________
37. If you are pleading guilty/no contest to more than one charge, do you understand that you may be sentenced consecutively and the maximum punishment for these crimes is years imprisonment and a fine of $_________ plus court costs? ________
38. Does this crime(s) have a mandatory punishment? _________
39. If so, do you understand that the Court cannot suspend any portion of the mandatory sentence of years? ___________
40. Are you aware there is no parole in Virginia? ___________
41. Have you discussed the sentencing guidelines with your attorney, and do you understand that the Court is not required to follow those guidelines? ___________
42. Do you understand that if you are not a citizen of the United States and if you plead guilty/no contest or are found to be guilty, there may be consequences of deportation, exclusion from admission into the United States, or denial of naturalization pursuant to the laws of the United States? ______________
43. Are you totally satisfied with the services of your attorney?
44. Did you review all of the questions on this form with your attorney? _________
45. Did you understand all of the questions on this form and any questions that may have been asked of you, and all of the answers that you gave? ______
46. Have your answers been truthful? _________
47. Do you have any questions to ask the Court? _________
48. If so, please write your questions below:
______________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
DATE: _______________________
_____________________________
Defendant
_____________________________
Attorney for Defendant
A Copy,
Teste:
_________________________________
Clerk
Va. Sup. Ct. Form 6