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# In the Court of Common Pleas of ___ County

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Case number: _____

VS.

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# Interpreter Waiver Form

Name of party waiving the services of an interpreter: _____


<table border=1 style='margin: auto; word-wrap: break-word;'><tr><td colspan="5">Name of party waiving the services of an interpreter:</td></tr><tr><td style='text-align: center; word-wrap: break-word;'>Relationship to case: (Check one)</td><td style='text-align: center; word-wrap: break-word;'>Defendant/Respondent</td><td style='text-align: center; word-wrap: break-word;'>Plaintiff/Petitioner</td><td style='text-align: center; word-wrap: break-word;'>(Print name) Witness</td><td style='text-align: center; word-wrap: break-word;'>Victim</td></tr><tr><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'>Parent/Person in loco parentis</td><td colspan="3">Other:</td></tr></table>

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

Date

By the court