Va. Sup. Ct. R. pt. 3A, 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