After having investigated the facts and circumstances underlying the defendant's wish to waive the right to counsel, including the defendant's background, employment, education, and desires, and after having warned the defendant of the dangers and disadvantages of proceeding without legal representation, I have determined that this defendant has knowingly, voluntarily, and intelligently waived the right to counsel and the right to court-appointed counsel if the defendant is indigent.

This _____ day of __________, 19___.


______________________________
Judge, ______ Court of ______ County

In the ______ Court of ______ County

State of Georgia

v.

Defendant _________________________

Case No. _______________________

Record of Defendant Prior to Entering a Plea

The Defendant in this case, being duly sworn, states as follows:

I am not under the influence of alcohol or drugs and I am not suffering from any mental or physical disability.

I have been advised of the nature of the charge(s) against me, the maximum and minimum punishment provided by law and my right to be represented by a private attorney, or by a public defender, if I am eligible.

I understand that by entering a plea of guilty or nolo contendere that I waive:

(1) The right to trial by jury;

(2) The presumption of innocence;

(3) The right to confront witnesses against me;

(4) The right to subpoena witnesses;

(5) The right to testify and to offer other evidence;

(6) The right to assistance of counsel during trial; and

(7) The right not to incriminate myself.

I now desire to enter my plea of __________________________ to the charge against me. It Is free and voluntary. I have not been told what sentence will be imposed. No promises or threats have been made to me by and District Attorney, Solicitor, Lawyer, Policeman or other person to induce me to enter this plea.

___________ I am not represented by a lawyer. I understand the nature of the charges against me and consequences of my plea. I freely and voluntarily waive the benefit of counsel and choose to represent myself in this plea proceeding.

I understand that if I am placed on non-reporting or reporting probation, I cannot violate any criminal laws of any governmental unit or any special conditions of probation without being subject to revocation for the balance of the sentence.

______________________________________________
Defendant                      Date

______________________________________________
Prosecutor                     Date

______________________________________________
Attorney                       Date

I have satisfied myself that this defendant's plea is free and voluntary and that he/she is in possession of his/her faculties and is able to understand the nature and consequences of his/her plea. I have also determined that this defendant understands he/she has the right to the assistance of counsel at this plea proceeding and knowingly, voluntarily, and intelligently waives the right to counsel if not represented by counsel. The court is further satisfied there has been a sufficient factual basis shown for the acceptance of this plea, and the defendant understands the consequences of his/her plea.

______________________________
Judge, ______ Court of ______ County