Form 63
CRIM DIV
Revised 4/19/18
9-9-2020
☐Yes
8. Do you understand that if any errors occur throughout the trial that are not timely objected to or
otherwise raised by you, as a defendant, said objections cannot later be raised upon appeal?
☐No
9. Do you understand that you do not have to disclose your immigration or citizenship status to the
Court, but if you are not a citizen of the United States, you have the right to receive advice from
a lawyer about the specific consequences and risk that your case may have on your immigration
status. You are not entitled to an immigration lawyer at public expense. Depending on the facts
of your case, a plea of guilty or a conviction at trial can result in your deportation and may have
other negative immigration consequences, such as preventing you from gaining citizenship or
lawful status to remain in the United States. In some cases, if you are convicted, detention and
deportation will be required. This is a complicated area of law and, if applicable, it is strongly
advised that you talk with an attorney. Do you wish to consult with an attorney regarding your
immigration or citizenship status? ☐Yes ☐No
10. How old are you? ___________ What is your date of birth? __________________
11. How far did you go in school? ______________________ Do you read, write and understand
the English Language? ☐Yes ☐No
12. Have you had any narcotics or alcohol in the last 48 hours? ☐Yes
☐No
13. Have you ever suffered from any mental or physical illness that would disturb your thinking here
today or in any way influence your waiver of the right to counsel? ☐Yes ☐No
☐No
14. Do you completely understand these proceedings? ☐Yes
15. Has anybody forced you to waive your right to counsel? ☐Yes
☐No
☐No
16. Are you doing this of your own free will? ☐ Yes
17. Have any threats been made to you to waive your right to counsel? Yes
☐No
Defendant’s
Initials
