Philadelphia Cnty. C.P. Municipal Court-Traffic Local Rule 121

The Waiver of Counsel Form execut ed by a defendant pursuant to Pa.R.Crim.P. 121 shall be as

follows:

WAIVER OF COUNSEL FORM

WAIVER OF COUNSEL

Commonwealth Of Pennsylvania Citation Number(s):

_____________________________ Date of Birth: ______________

Defendant’s Name

I hereby state and affirm that I have been advised and that I understand that:

I have the right to be represented by counsel, and the right to have free counsel appointed

if I cannot afford one; if I am convicted my operating privileges license could be suspended,

and that if I am convicted I may receive a prison sentence; if I waive the right to counsel,

I will still be bound by all the normal rules of procedure and that counsel would be familiar

with these rules; there are possible defenses to these charges that counsel might be aware

of, and if these defenses are not raised at trial, they may be lost permanently; and that, in

addition to defenses, that I may have many rights that, if not timely asserted, may be lost

permanently; and that if errors occur and are not timely objected to, or otherwise timely

raised by me, these errors may be lost permanently.

and I choose to act as my own attorney in connection with the summary trial or hearing for the citation(s) listed above.

I further state and affirm that my waiver is made knowingly, voluntarily, and intelligently.

__________________________________ ______________________

Defendant Date

I certify that the defendant’s waiver was made knowingly, voluntarily and intelligently.

__________________________________ ______________________

Date

Note: Adopted December 21, 2005, effective on February 1, 2006; amended on

May 8, 2014. Effective June 23, 2014.