DEFENSE OF INDIGENTS ACT

FORM NO. 3

CERTIFICATE OF JUDGE

I hereby certify that the above-named defendant has been fully informed in open Court of the charges against him and of his right to have counsel appointed by the Court to represent him in this case; that he has elected in open Court to be tried in this case without the appointment of counsel; and that he has executed the above waiver in my presence after its meaning and effect have been fully explained to him.

This day of ,

____________________________________

Judge

CERTIFICATE OF JUDGE

I hereby certify that the above-named defendant has been fully informed in open Court of the charges against him and of his right to have counsel appointed by the Court to represent him in this case; that he has elected in open Court to be tried in this case without the appointment of counsel and that he has refused to sign a waiver.

This day of ,

____________________________________

Judge

DEFENSE OF INDIGENTS ACT

wclark

2003-02-25

cyon

scjd