Commonwealth of Pennsylvania V.

Waiver of Jury Trial

Docket No: CP-01-CR-___-20___

11. Are you completely satisfied with the representation and legal advice of your attorney?
12. <div style="text-align: center;"><img src="imgs/img_in_image_box_18_57_273_63.jpg" alt="Image" width="86%" /></div>
12. Has anybody forced you, or attempted to force you, in your decision to waive constitutional right to a trial by jury? ___
13. <div style="text-align: center;"><img src="imgs/img_in_image_box_23_28_273_76.jpg" alt="Image" width="85%" /></div>
13. Has anybody promised you anything for waiving your constitutional right to a trial by jury?
14. .
14. Are there any further questions concerning your right to a jury trial, your waiver of that right, or the charges against you, which you would like to ask the court?

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As attorney for the defendant, I, _____, hereby certify that I have advised my client of the rights and the meaning of the questions contained in this form and it is my belief that the defendant understands these rights and that it is the defendant's voluntary decision to proceed non-jury.

Signature of Attorney for the Defendant

Date

CPCMS 2007 (05/25)