The Court has advised me that I have the right to be represented by an attorney and if indigent to have an attorney appointed to represent me.  I WAIVE MY RIGHT TO AN ATTORNEY AND WISH TO PROCEED IN THIS CASE WITHOUT AN ATTORNEY.
____________	________________________________
Date	Defendant		I find the Defendant understands and freely and voluntarily waives the right to an attorney

___________		_______________________________
Date			Judge	

(  ) I waive my right to a preliminary examination and agree for my case to be bound over to the __________________________________ County Grand Jury.
(  ) I waive my right to be tried only after being indicted by the Grand jury and waive my right to a trial by jury and plead NOT GUILTY to violation(s) of TCA
_______________________________________________________________________________________________________________________________________

___________________________________________		________________		______________________________________________________
Attorney for Defendant				Date			Defendant

Tenn. R. Crim. P. 44 requires defendants to execute a written waiver of the right to counsel.  However, the Court must also orally explain many rights, and the effect of a waiver of those rights, prior to accepting the defendant’s waiver.  See Tenn. R. Crim. P. 44(a); Smith v. State, 987 S.W.2d 871 (Tenn. Crim. App. 1998).

I plead GUILTY to violation of T.C.A.__________________________________.  I have been advised by the Court of the following:  (1) the nature of the charge(s) to which the plea is offered; (2) the mandatory minimum penalty provided by law, if any, and the maximum possible penalty provided by law; (3) if applicable, a different or additional punishment may result by reason of my prior conviction(s) or other factors which may be established in the present action after the entry of my plea; (4) if applicable, any prior convictions may be presented to the Court for its consideration in determining punishment; and (5) that I have the following rights:  (a) to be prosecuted only upon an indictment or presentment; (b) to be represented by an attorney at every stage of the proceeding and, if necessary, to the appointment of an attorney; (c) to plead not guilty or to persist in that plea if it has already been made; (d) to be tried by a jury and to the assistance of an attorney at such a trial; (e) to confront and cross-examine witnesses against me; (f) not to be compelled to incriminate myself; (g) to have an appellate court review the basis of my conviction; and (h) to have a jury set any fine greater than $50.00.  

I understand that if I plead guilty I waive all of these rights, including my right to a trial.  I understand that there will not be a trial of any kind.  Pursuant to the terms of my plea agreement, there □ will □ will not be a sentencing hearing.  I understand that if I plead guilty I may be asked questions about the offense(s) to which I have pleaded, and if I answer these questions under oath, on the record, and in the presence of counsel, my answers may later be used against me in a prosecution for perjury or aggravated perjury.  After carefully considering all of these matters, I voluntarily waive my rights and request that the Court accept my plea of GUILTY.   
 	
__________________________________________		_________________		_____________________________________________
Attorney for Defendant		Date		Defendant

I addressed the defendant personally in open court, advised him/her of the rights itemized above, inquired into his/her understanding of the consequences of entering a guilty plea, and inquired into the accuracy of the plea.  I hereby conclude that the defendant understands his/her rights, that the plea is voluntary and not the result of force or threats or of promises apart from a plea agreement, that there is a factual basis for the plea, and that the defendant’s willingness to plead guilty results from prior discussions between the District Attorney General and the defendant or the defendant’s attorney.  I find that the plea of GUILTY heretofore entered by the defendant is acceptable and, therefore, accept the plea.  The judgment and sentence shall reflect the disposition provided for in the plea agreement.

__________________________________________		_________________
Judge						Date		
GENERAL SESSIONS COURT OF ___________________________________________________________ COUNTY TENNESSEE 

State of Tennessee vs.  ___________________________________________________________________________________________________________________

State Control # ______________________________		_______________________ County	Case # _______________________________________

JUDGMENT 

	(  ) Dismissed	(  ) Not Guilty	(  ) Nolle Prosequi	( ) Pretrial/Judicial Diversion ______________________________________________________

	 Costs taxed to the Prosecutor _______________________________________________________________________________________________________
	(  ) State’s motion to not prosecute	(  ) after preliminary hearing	(  ) affiant did not appear	(  ) Defendant waived extradition

	 Cost taxed to the Defendant ________________________________________________________________________________________________________
	(  ) Costs and taxes		(  ) Cost

	 Defendant cannot pay fine, costs, and taxes today – due __________________________________________________________________________________

	 Defendant Indigent _______________________________________________________________________________________________________________

	 Found GUILTY of violation of TCA _________________________________________________________________________________________________
	fined $ ______, taxed with costs and taxes and sentenced to serve ______ months ______ days in the ____________ County Jail (Class______ Misd.)

	 Found GUILTY of violation of TCA _________________________________________________________________________________________________
	fined $ ______, taxed with costs and taxes and sentenced to serve ______ months ______ days in the ____________ County Jail (Class______ Misd.)

	 Found GUILTY of violation of TCA _________________________________________________________________________________________________
	fined $ ______, taxed with costs and taxes and sentenced to serve ______ months ______ days in the ____________ County Jail (Class______ Misd.)

	 Jail sentence suspended except ____________________________________ on condition of good behavior, payment of fines, costs and taxes and restitution of 
	$_______ to __________________________________________________________ and (  ) no contact with ________________________________________
	(  ) supervised probation for _________________________________________ (  ) unsupervised probation for _______________________________________ 
	(  ) not drive in Tennessee for ______ year(s) and completion of (  ) DUI school	(  ) alcohol/drug evaluation and counseling	(  ) domestic abuse counseling
	(  ) ____________ hours of community service __________________________________________________________________________________________.
	To report to serve on ____________ at ______ am/pm.  Time served credit _________ 	(  ) Sentence may be served on consecutive weekends

	 Release eligibility date is ___________________________ % of the term of imprisonment

	 (  ) Appealed	(  ) Defendant bound over to ______________________ County Grand Jury after (  ) preliminary hearing  (  ) waiving preliminary hearing and 
	 (  ) bail set at $_________  (  ) Defendant shall continue on current bond of $ ___________________________

	 Other ___________________________________________________________________________________________________________________________________________________________________

	 See separate sentencing order

_________________________________________			_________________________________________________
Date				Judge