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In the Court of Common Pleas of ___ County

In the Court of Common Pleas of

___

undefined

VS. ___

Case number: _____

Case number

Interpreter Waiver Form

Name of party waiving the services of an interpreter: _____

Print name

Name of party waiving the services of an interpreter:

Relationship to case: (Check one) Defendant/Respondent Plaintiff/Petitioner (Print name) Witness Victim

Parent/Person in loco parentis

Plaintiff/Petitioner Witness Victim

(Print name)

Parent/Person in loco parentis Other:

Other

Parent/Person in loco parentis

Other: ______________________________

Primary language spoken: _____

Secondary language

Primary language spoken

Secondary language: _____

I, the undersigned, have been advised by the court of my right to have an interpreter present for the duration of this court proceeding to assist me in fully participating and understanding the proceeding, in order to safeguard my due process rights.

However, after consulting with my attorney, through the services of the interpreter provided by the court, (pursuant to 204 PA Code Ch.221.105 (a) or (b)), I hereby knowingly, voluntarily and intelligently choose to waive my right to have an interpreter present to assist me during these proceedings.

I understand that if at any time during the proceeding I decide that I need the services of an interpreter, one will be provided if I so petition the court.

Signature of party waiving the interpreter

Signature of Counsel for party waiving the interpreter

Signature of party waiving the interpreter

Signature of Counsel for party waiving the interpreter

Interpreter signature

Date

By the court