DEFENSE OF INDIGENTS ACT

FORM NO. 1

A STATEMENT OF THE RIGHTS OF AN ACCUSED

You have been arrested and charged with the crime of .

You are advised:

(a) You have a right to employ counsel to represent you.

(b) In the even you are financially unable to employ counsel, the State will provide you with counsel by appointment or with the services of the Public Defender of the County. If you desire the State to provide you with counsel, you may make application for counsel on a form which I will give to you.

The form has been read to the accused, in my presence, at o’clock p.m. a.m., this day of , .

___________________________________

Clerk of Court

or other Officer

(if the accused cannot employ counsel and does not wish the State to provide him with counsel at this time, he shall be asked to execute the following statement.)

WAIVER OF RIGHT TO HAVE APPOINTED

COUNSEL OR SERVICES OF PUBLIC DEFENDER

The undersigned certifies that he has been informed of the charges against him and the nature thereof, and that he is unable to employ counsel. However, the undersigned now state that he does not at this time desire to apply for the appointment of counsel or for the services of the Public Defender, and expressly waives his desire to services of counsel provided by the State at this time, which he understand he has a right to do.

____________________________________

Defendant

Executed before me this day of , .

____________________________________

Signature of Clerk

of Court or Officer

DEFENSE OF INDIGENTS ACT

wclark

2003-02-25

scjd