Fillable IN THE COURT OF COMMON PLEAS OF ALLEGHENY (Fifth Judicial District of Pennsylvania)

Fill Online, Printable, Fillable, Blank IN THE COURT OF COMMON PLEAS OF ALLEGHENY (Fifth Judicial District of Pennsylvania) Form

Use Fill to complete blank online FIFTH JUDICIAL DISTRICT OF PENNSYLVANIA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

IN THE COURT OF COMMON PLEAS OF ALLEGHENY (Fifth Judicial District of Pennsylvania)

On average this form takes 45 minutes to complete

The IN THE COURT OF COMMON PLEAS OF ALLEGHENY (Fifth Judicial District of Pennsylvania) form is 32 pages long and contains:

  • 2 signatures
  • 14 check-boxes
  • 166 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Fifth Judicial District of Pennsylvania forms online.

BROWSE FIFTH JUDICIAL DISTRICT OF PENNSYLVANIA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
IN THE COURT OF COMMON PLEAS OF ALLEGHENY COUNTY, PENNSYLVANIA
CRIMINAL DIVISION
COMMONWEALTH OF PENNSYLVANIA,
vs.
Case No.
Defendant
REQUEST FOR REMOTE HEARING
DATE LISTED FOR TRIAL: DATE OF REQUEST:
To be submitted 4 days prior to Date Listed
Counsel of Record
Assistant District Attorney
Attending Remotely: YES
NO
Defense Counsel
Attending Remotely: YES NO
Email Address Email Address
Telephone Telephone
Email and Telephone for Defendant
(if attending remotely from another
location)
DOCUMENTATION TO BE PROVIDED
COMMONWEALTH DOCUMENTATION DEFENSE DOCUMENTATION
□ Plea Summary
□ Guidelines
□ Restitution (if applicable)
□ Remote Hearing Form
□ Guilty Plea Colloquy
□ Supplemental Waiver Colloquy
□ Sorna Colloquy (SOC cases)
□ Charge Specific Conditions (SOC cases)
If Defendant is remote or incarcerated, please fill out the following:
□ Probation Intake Information Sheet
□ Rules of Probation
The Honorable
2.1.21
IF YOUR CLIENT IS INCARCERATED, YOU MAY USE THE LINK BELOW TO SET UP A VIRTUAL APPOINTMENT:
https://www.alleghenycounty.us/jail/contact/professional-visits.aspx
IF THE GUIDELINES ON THIS CASE CALL FOR INCARCERATION AND DEFENDANT IS OUT ON BOND, A REMOTE
HEARING IS NOT APPROPRIATE AND THIS FORM IS NOT NEEDED.
IN THE COURT OF CO
MMON PLEAS OF ALLEGHENY COUNTY, PENNSYLVANIA
COMMONWEALTH OF
PENNSYLVANIA : CRIMINAL DIVISION
vs. :
________________________________ : CC No. _____________________
GUILTY PLEA
EXPLANATION OF DEFENDANT’S RIGHTS
You or your attorney have indicated to the officers of this Court that you wish to plead guilty to certain
specific criminal charges which the Commonwealth of Pennsylvania has brought against you.
To have your plea accepted by this Court here today, you must waive your right to confront the
prosecution witnesses against you and agree to permit the Attorney for the Commonwealth to summarize
the Commonwealth’s evidence against you. You must agree to stipulate to the authenticity and accuracy of
any Crime Laboratory reports presented by the Commonwealth and to the chain of custody of any of the
Commonwealth’s evidence involved in your case.
You must fully understand that your plea must be voluntary and no clemency is being promised in
exchange for your plea, with the exception of any plea bargain or arrangement previously agreed to between
your attorney and the Assistant District Attorney assigned to your case.
By pleading guilty to any charge, you are admitting that you committed that offense. The
Commonwealth would not have to prove beyond a reasonable doubt each and every element of the offenses
with which you are charged as would be required in a jury or non-jury trial.
Please be advised that you must fully understand that the Constitution of the United States of America
and the Constitution of the Commonwealth of Pennsylvania give to you an absolute right to have a trial by
judge or by jury.
2.1.21
______________
Defendant's Initials
If you intend to waive your Constitutional right to a trial by judge or by jury, please answer all the
questions on this form. Most of the questions are designed to be answered “yes” or “no.” Where general
information is requested, please answer the question as fully as possible.
If you do not understand the question, you should say so in writing on this form. You should also tell
your lawyer and the judge who hears your case so they can explain it to you. You must fully understand all of
your rights before the judge can accept your plea.
You should initial each page at the bottom after you have read, understood, and completed your
answers to the questions on that page. When you have finished all of the questions, you must sign the form
at the end.
1. What is your full name? ________________________________________________
2. How old are you today? __________________________
3. What is the highest grade that you have completed in school? _______________________
Answer either "Yes" or "No" to the following questions:
4. Do you read, write, and understand the English language? ____________
5. Do you understand that if you have been charged with more than one offense, the
Court may impose a separate, or consecutive, sentence for each offense? __________
6. Have you discussed with your attorney the elements of each charged offense? ______
7. Have you discussed with your attorney the factual basis of each charged offense?
__________
8. Have you discussed with your attorney how the facts in your case prove the elements
of each charged offense? __________
9. Do you understand that both the Constitution of the United States of America and the
Constitution of the Commonwealth of Pennsylvania give you an absolute right to a trial
by jury? __________________
2.1.21
___________________
Defendant's Initials
10. Do you understand that if you want a jury trial, you could take part in the selection of the jury under
Court supervision along with your attorney and with the Assistant District Attorney assigned to
prosecute your case? __________
11. Do you understand that you and your attorney and the Assistant District Attorney assigned to
prosecute your case would select a jury from a panel of jurors randomly selected by computer from
the voter registration lists and other legally approved lists of citizens of Allegheny County?
___________
12. Do you understand that both the defense and prosecution would have the right to “challenge”
members of the jury panel and that this means you and the prosecution would have the right to cause
certain persons on the jury panel from being a member of the jury in your case? _____________
13. Both you and the prosecution would have as many challenges “for cause” as the court would approve.
“For cause” means a good reason why the challenged person could not be a fair and impartial juror in
your case. Do you fully understand this? ______________
14. Both you and the prosecution would each also have a number of peremptory challenges. A
peremptory challenge is one in which no reason has to be given to prevent a prospective juror from
being a member of your jury. If you are charged with felonies, both you and the prosecution each have
seven peremptory challenges. If you are charged only with misdemeanors, both you and the
prosecution each have five peremptory challenges. Do you fully understand this? ______________
15. All twelve members of the jury finally selected would have to be satisfied that the Commonwealth had
proven your guilt beyond a reasonable doubt on each and every element of the charges; that is, the
vote of all twelve must be unanimous before you could be found guilty. Do you fully understand this?
___________
16. You also may choose to be tried before a judge without a jury in what is called a non-jury or bench trial
and that the judge, in addition to ruling on legal questions and defining the law as in jury trials would
also sit as the trier of fact, the same as a jury in a jury trial; and it would be the judge who determines
from the evidence presented whether the Commonwealth has proven you guilty beyond a reasonable
doubt. Do you fully understand this? _________
2.1.21
___________________
Defendant's Initials
17. In either the jury trial or non-jury trial before a judge, you enter the courtroom clothed with the
presumption of innocence and that presumption remains with you until such time that all the
members of the jury or the judge in a non-jury trial, would find you guilty beyond a reasonable doubt.
Do you fully understand this? ____________
18. In either a jury trial or non-jury trial, it is the burden of the Commonwealth to prove you guilty “beyond
a reasonable doubt,” and to do this the Commonwealth must prove each and every element of the
crime or crimes with which you are charged “beyond a reasonable doubt” to the satisfaction of all
twelve jurors or to the satisfaction of the judge. Do you fully understand this? ___________
19. A reasonable doubt is an honest doubt arising from the evidence presented or from the lack of
evidence, and it is the kind of doubt that would cause a reasonable, prudent person to pause and
hesitate before acting in a matter of importance in their own affairs. Do you fully understand this?
____________
20. In either a jury trial or a non-jury trial, you have the absolute right to remain silent and need not
present any evidence in your own behalf and there is no burden placed on you to prove your own
innocence or, for that matter to prove anything since the burden is always on the Commonwealth to
prove you guilty beyond a reasonable doubt. Do you fully understand this? __________
21. However, in either a jury trial or a non-jury trial before a judge, you have the right, if you so desire, to
testify and present evidence on your behalf. You also would have the right, either yourself or through
your attorney, to cross-examine or question any witnesses presented by the Commonwealth in order
to test their credibility and the truthfulness of their testimony. Do you fully understand this?
___________
22. By pleading guilty, you are giving up all of these rights described in the previous questions. Do you
fully understand this? _________
23. Do you understand that if you are not a citizen of the United States, whether or not you have lawful
immigration status, your plea or admission of guilt may result in detention, deportation, exclusion from
the United States, or denial of naturalization or other immigration benefits? You have the right to seek
advice from a lawyer about these issues before you admit guilt to any offense. You are not entitled to
an immigration lawyer at public expense. Upon request, the court may allow you additional time to
consult with an immigration attorney. Do you understand this? ____________
2.1.21
___________________
Defendant's Initials
24. When you plead guilty, the Commonwealth would not have to prove each and every element of the
crime or crimes with which you are charged by the presentation of witnesses and/or other evidence
but the Assistant District Attorney could simply present a summary of the evidence against you. Do
you fully understand this? _______________
25. By pleading guilty, you are admitting you committed the crimes charged. You are stating that you do
not challenge or dispute the charges against you. Do you fully understand this? ___________
26. By pleading guilty, you give up the right not only to file pretrial motions, but also you abandon or give
up any pretrial motions already filed and not yet decided and any pretrial motions in which decisions
were already made. Do you fully understand this? ____________
27. Do you understand that by pleading guilty, you also give up the right to present or assert any defenses
on your behalf? ______________
These defenses might include alibi, self-defense, mental infirmity, or insanity. Have you discussed with
your attorney why these defenses are not available in your case? __________
28. If you were convicted after a jury trial or non-jury trial, you could appeal the verdict to the appellate
courts and raise any errors that were committed in the trial court, and this could result in a new trial or
a dismissal. By pleading guilty, you are giving up this right. Do you fully understand this?
_____________
29. Do you fully understand that if you were convicted after a jury trial or a non-jury trial before a judge,
you could challenge in this Court and in the appellate courts whether the Commonwealth had
presented enough evidence to prove you guilty beyond a reasonable doubt? ____________
30. By pleading guilty, you give up certain rights of appeal; in a jury trial or a non-jury trial, you would have
the right to appeal any errors that might arise in your case to the appellate courts. However, when you
plead guilty, you limit the grounds for those appeals to four specific reasons:
1. that this Court did not have jurisdiction in your case. With rare exception, this Court only
has jurisdiction where the crime was committed in Allegheny County;
2.1.21
___________________
Defendant's Initials
2. that the sentence or probation imposed by this Court is illegal;
3. that your plea was not knowingly, intelligently, and voluntarily made; and
4. Challenge the competence or effectiveness of the attorney who represents you.
All other grounds for appeal are given up. Do you fully understand this? ____________
31. In order to raise a claim on direct appeal that your attorney was ineffective or incompetent, it is
necessary for you to first raise that claim in a post sentence motion, filed within ten (10) days of your
sentencing. Otherwise, you cannot challenge the competence of your attorney until the post
conviction stage. Do you fully understand this? ____________
32. Do you understand that you have the right to file a motion seeking to withdraw your guilty plea at any
time prior to the date of sentencing? ______________
33. Do you understand that you must be sentenced within ninety (90) days of the date of the entry of your
plea of guilty? __________________
34. Do you understand you have the right within ten (10) days after you have been sentenced to file a
motion seeking to withdraw your guilty plea? ____________
35. If you were to file a motion seeking to withdraw your plea of guilty, either prior to sentencing or within
ten (10) days after sentencing, that motion must be filed in writing. If you would fail to do so within
these time periods, you would give up those rights. Do you fully understand this? ________________
36. In order to appeal your conviction that results from your plea of guilty, you must file in writing your
motion seeking to withdraw your plea, either prior to sentencing or within ten (10) days after
sentencing and state one or more of the four (4) grounds listed below as the basis for a motion seeking
to withdraw your plea:
(a) Your plea was not knowing, intelligent and voluntary;
(b) That your crime was not committed within the jurisdiction of this Court,
i.e. not committed within Allegheny County;
2.1.21
___________________
Defendant's Initials
(c) That the sentence of this Court is illegal; and/or,
(d) That your attorney was ineffective and incompetent.
If you do not file this motion within the proscribed time limits, you will have given up this right. Do you fully
understand this? ________________
37. If your motion seeking to withdraw your plea of guilty, which is filed prior to sentencing, is denied you
would have ten (10) days from the date of sentencing to file with this Court a post-sentencing motion
challenging the denial of your motion to withdraw your plea of guilty. Do you fully understand this?
_____________
38. Following the imposition of sentence upon you for your entry of a plea of guilty, you have the right to
file post-sentencing motions with this Court which include:
(a) a motion challenging the validity of a plea of guilty;
(b) a motion challenging the denial of a motion seeking withdrawal of a plea of guilty;
(c) a motion to modify sentence.
Do you fully understand these rights? ____________
39. If you would file any post-sentencing motions, those motions must be decided by this Court within one
hundred twenty (120) days of the date of filing of said motions, or within one hundred fifty (150) days
of the date of filing of those motions if you sought and were granted a thirty (30) day extension, which
extension only you can request. Do you fully understand this? ___________
40. If your post-sentencing motions are not decided within one hundred twenty (120) days of the date of
filing, or within one hundred fifty (150) days of the date of filing, if you sought and received a thirty
(30) day extension, then said motions are deemed to have been denied by operation of law and cannot
be reconsidered by the trial Court. Do you fully understand this? ______________
41. Should your post-sentencing motion be denied by this Court or by operation of law, you will receive,
either from the trial Court or from the Department of Court Records, an order of court advising you of
your appellate rights, the right to assistance of counsel, if indigent, the right to proceed in forma
pauperis, and the qualified right to bail. Any appeal to the Superior Court must be filed within thirty
(30) days of the denial of your post-sentencing motion. Do you fully understand this? ___________
2.1.21
___________________
Defendant's Initials
42. If you wish to file any of these motions with this Court or an appeal to the Superior Court of
Pennsylvania and cannot afford an attorney to assist you to do so, the trial Court will appoint an
attorney for you at no cost to you. Do you fully understand this? ______
43. When you plead guilty, and your plea is accepted by this Court, all that remains is for the judge to
sentence you on the charges to which you are pleading; but if your plea is rejected, you have the right
to proceed with a trial. Do you fully understand this? ___________
44. Have you and your attorney discussed the maximum possible sentences which this Court could
impose? ___________
45. If there is a mandatory minimum sentence applicable and this mandatory sentence is sought by the
Commonwealth, then this Court has no discretion to impose a lesser sentence and must impose at
least the minimum sentence that is required by law. Do you fully understand this? ___________
46. Are you aware that if the offenses with which you are charged do not require a mandatory sentence
under the statutory law of Pennsylvania, this Court is not bound by the sentencing guidelines and may
deviate from the guidelines; however, if the Court does so, both the District Attorney and you would
have a right to appeal such deviation? ___________
47. Do you understand that if you are entering a plea of guilty to the charge of Violation of the Vehicle
Code: Driving Under the Influence of Alcohol, a Controlled Substance or both that independent of any
sentence this Court might impose, the Department of Transportation has the right, upon receipt of
notice of this conviction, to impose an additional penalty upon you? __________
48. Do you understand that any term of imprisonment imposed as a result of your plea may be imposed
separately or consecutively, with any other sentence you are currently serving? _________
49. Do you understand that your plea of guilty or nolo contendere violates any period of parole or
probation that you are currently serving, either state or federal, as long as the crime or crimes you
were convicted of or plead to occurred during those periods of probation or parole? ________
2.1.21
___________________
Defendant's Initials
50. Do you understand that if your plea of guilty or nolo contendere violates a period of parole or
probation, either state or federal, you would be subjecting yourself to an additional penalty for the
violation of those periods of parole and/or probation and a new sentence could be issued for each
violation and those sentences could be imposed consecutively to the sentence imposed upon you for
your plea of guilty or nolo contendere in this case? ______________
51. Are you eligible for a RRRI sentence? ____________
52. Your plea must be voluntary and your rights must be voluntarily, knowingly, and intelligently waived. If
anyone has promised you anything other than the terms of a plea bargain, your plea will be rejected. If
anyone has forced you or attempted to force you in any way to plead guilty, your plea will be rejected.
Do you fully understand this? __________
53. Has anybody forced you to enter this plea? __________
54. Are you doing this of your own free will? ____________
55. Have any threats been made to you to enter a plea? ___________
56. Has anyone (including your attorney) promised you anything in exchange for the guilty plea other than
the terms of any plea bargain? __________
57. Do you understand that if there is a plea bargain in this case, the terms of the plea bargain will be
stated on the record before the judge and that you will be bound by the terms of the plea bargain as
they appear of record? ____________
58. Do you understand that the Court is not bound by any plea bargain entered into by you and the District
Attorney? ____________
2.1.21
___________________
Defendant's Initials
59. If the Court rejects the plea bargain after hearing a summary of the evidence, you would then have a
right to withdraw your plea and you would have the option of entering a straight plea with no plea
bargain involved or, have a trial by jury if you so desire. Do you fully understand this? ___________
60. Is there a plea bargain in this case? __________
61. Are you satisfied with the legal advice and legal representation of your attorney? __________
62. Have you had ample opportunity to consult with your attorney before entering your plea, and are you
satisfied that your attorney knows all of the facts of your case and has had enough time within which
to check any questions of fact or law which either you or your attorney may have about the case?
__________
63. Has your attorney gone over with you the meaning of the terms of this document? ____________
64. Do you have any physical or mental illness that affects your ability to understand these rights or the
voluntary nature of your plea? ____________
65. Are you presently taking any medication which affects your thinking or your free will? ____________
66. Have you had any drugs or alcohol in the past forty-eight (48) hours? _________
67. If you are entering a plea of guilty, you admit that you committed the crime(s) with which you are
charged. Do you fully understand this? __________
2.1.21
___________________
Defendant's Initials
68. Do you understand your rights? __________
I AFFIRM THAT I HAVE READ THE ABOVE DOCUMENT IN ITS ENTIRETY, I UNDERSTAND ITS FULL
MEANING, AND I AM STILL NEVERTHELESS WILLING TO ENTER A PLEA TO THE OFFENSES SPECIFIED. I
FURTHER AFFIRM THAT MY SIGNATURE AND INITIALS ON EACH PAGE OF THIS DOCUMENT ARE TRUE
AND CORRECT.
DATE: _____________________________ ____________________________________
Signature of Defendant
2.1.21
_________________
Defendant's Initials
CERTIFICATION OF DEFENSE COUNSEL
I certify that:
(1) I am an attorney admitted to the Supreme Court of Pennsylvania.
(2) I represent the defendant herein.
(3) I know no reason why the defendant does not fully understand everything that is being said and done here
today.
(4) The defendant read the above form in my presence and fully understands it; I have gone over the form
completely with the defendant, explained all of the items on the form and answered any questions he or she
had.
(5) I see no reason why the defendant cannot and is not knowingly, intelligently, and voluntarily giving up his or her
rights to trial and pleading guilty.
(6) I made no promises to the defendant other than any that appear of record in this case.
DATE: ________________________
_____________________________________________
Attorney for Defendant
2.1.21
CERTIFICATE OF COMPLIANCE
I certify that this filing complies with the provisions of the Public Access Policy of the Unified Judicial System of
Pennsylvania: Case Records of the Appellate and Trial Courts that require filing confidential information and
documents differently that non-confidential information and documents.
Submitted by: _________________________
Signature: ____________________________
Name: _______________________________
Attorney No. (if applicable):______________
Please email this completed form to the assigned Assistant District Attorney AND the staff of the assigned Judge.
(For the email address of judicial staff, go to www.AlleghenyCourts.us/Criminal
and select "Chambers E-mail Directory.")
2.1.21
IN THE COURT OF COMMON PLEAS OF ALLEGHENY COUNTY, PENNSYLVANIA
COMMONWEALTH OF PENNSYLVANIA CRIMINAL DIVISION
v. Case Number(s):
______________________________,
Defendant
WAIVER OF RIGHTS AND CONSENT TO PLEA/SENTENCING BY VIDEO CONFERENCE
1. Do you understand that you have a right to appear in person before a judge when pleading
guilty or when being sentenced under Article 1, Section 9 of the Pennsylvania Constitution, as
well as Pa.R.Crim.P. 602 (Presence of the Defendant)? ___________
2. Do you agree to waive your right to be physically present in a courtroom when you to
plead guilty and/or are sentenced? ___________
3. Do understand that your court appearance will occur by video or telephonic
conference?___________
4. Do understand that you will not be able to appeal your guilty plea and/or sentencing based
upon you not being physically present in court? ___________
5. Do you consent to the judge accepting your guilty plea and imposing your sentencing via video
or telephonic conferencing? ___________
6. Do understand that you have a right to confront your accusers, question witnesses, and secure
the presence of various witnesses? ___________
7. Do you understand that your plea and sentencing will occur without requiring the police
officers, witnesses and/or victims in your case to appear in court? ___________
8. Do you understand that the witnesses, victims, and/or police officers in your case will not
be present in court, will not be subpoenaed, will not be called testify, and will not participate
in the video or telephonic conference? ___________
9. Do you understand that if you elected to exercise your right to a trial, whether by jury or
judge, the in-person testimony of these witnesses could be necessary to prove your guilt
beyond a reasonable doubt? ___________
10. Do you understand that if necessary witnesses did not appear at your trial listing, there is
a possibility your case would be dismissed? ___________
2.1.21
_________________
Defendant's Initials
11. Do you understand that by accepting this guilty plea you will not be able to raise on appeal
or withdraw your guilty plea based on the fact witnesses were not present? ___________
12. Your decision to waive your right to be physically present in the courtroom must be knowingly,
intelligently, and voluntarily waived. If anyone has promised you anything to waive your
physical presence, your plea will be rejected. If anyone has forced you or attempted to force
you to waive your physical appearance, your plea will be rejected. Do you fully understand
this?___________
13. Has any forced you to waive your physical appearance in the courtroom? ___________
14. Are you waiving your physical appearance in the courtroom of your own free will?
___________
15. Have any threats been made to you to waive your physical appearance in the
courtroom?___________
16. Has anyone (including your attorney) promised you anything in exchange for waiving your
physical presence in the courtroom? ___________
17. Have you discussed with your attorney your right to appear in person for your guilty
plea?___________
18. Are you satisfied with the legal advice and legal representation of your attorney? ___________
19. Do you have any physical or mental illness that affects your ability to understand the rights
you are waiving? ___________
20. Are you presently taking any medication which affects your thinking or your free will?
___________
21. Do you understand the rights you are waiving today? ___________
I AFFIRM THAT I HAVE READ THIS DOCUMENT IN ITS ENTIRETY, ANSWERED ALL OF THE
QUESTIONS TRUTHFULLY, AND FULLY UNDERSTAND EACH STATEMENT.
___________________________ ________________________
Defendant
Date
2.1.21
_________________
Defendant's Initials
Attorney Certification
I certify that I am an attorney admitted to practice law by the Supreme Court of
Pennsylvania and represent the defendant herein. I have reviewed the above document with
the defendant and the answers recorded belong to the defendant. I made no threats or
promises to the defendant to execute this document. I know of no reason that the
defendant cannot and is not knowingly, intelligently, and voluntarily waiving his or her
physical presence and waiving the presence of the witnesses/victims in this case.
I certify that this filing complies with the provisions of the Public Access Policy of the Unified
Judicial System of Pennsylvania: Case Records of the Appellate and Trial Courts that require
filing confidential information and documents differently than non-confidential information
and documents.
________________________
Date
________________________________
Defense Counsel
Attorney No.: ____________________
Please email this completed form to the assigned Assistant District Attorney AND the staff of the assigned Judge.
(For the email address of judicial staff, go to www.AlleghenyCourts.us/Criminal
and select "Chambers E-mail Directory.")
2.1.21
Court Approval
The Court, having ascertained on the record that the Defendant knowingly and
intelligently waives his/her right to be physically present and require the presence of the
witnesses/victims in this case, hereby does APPROVE / DISAPPROVES this waiver.
___________________________________
Judge
______________________________
Date
2.1.21
click to sign
signature
click to edit
ALLEGHENY COUNTY ADULT PROBATION INTAKE FORM
Date: _________
______________________________
Name: _____________________________________________________________________________________
(Last), (First) (Middle)
Alias (A.K.A): ______________________________________________________________________________
Address: __________________________________________________________________ ______________
(Street Address) (Apartment #)
__________________________, ________ ______________ County: ___________________
(City) (State) (Zip)
HOME PHONE:
CELL PHONE: (required)
WORK PHONE:
EMAIL ADDRESS:
Please provide a reference that would be able to quickly contact you if your assigned Probation Officer could not
reach you:
Name:
Relationship:
Phone:
Sentencing Judge: ________________________________________________________________________
CC#(s):
Signatur
e: __________________________________________ Date: ________________________________
*This form MUST be filled out in its entirety to ensure reliable and accurate information for your
probation officer to contact you upon receipt of your cas.
If contact cannot be established, a warrant
may be issued for your arrest*
*A probation officer will contact you via telephone, US mail, or email to schedule your initial interview*
*If you have any address or telephone number changes or need probation assistance prior to being
assigned a probation officer, please call 412-350-2320*
2.1.21
For Defendants either on Bond or Incarcerated, this form must be completed.
FIFTH JUDICIAL DISTRICT OF PENNSYLVANIA
ALLEGHENY COUNTY ADULT PROBATION DEPARTMENT
Name ______________________________Docket Number _____________________ OTN_______________
GENERAL RULES AND CONDITIONS OF PROBATION, PAROLE AND INTERMEDIATE PUNISHMENT (INCLUDING EM)
ACKNOWLEDGEMENT FORM
1. YOU MUST REPORT TO YOUR ASSIGNED PROBATION OFFICER as required and/or allow your probation officer to visit you at your home.
If you do not know who your probation officer is, call (412) 350-2320 between 8:30 a.m. and 4:30 p.m. Monday through Friday. Our 24-
hour emergency contact number is (412) 350-0400.
2. YOU MUST OBEY ALL LOCAL, STATE AND FEDERAL LAWS.
3. YOU MAY NOT POSSESS ANY FIREARM, AMMUNITION, OR PROHIBITED OFFENSIVE WEAPON AS DEFINED IN 18 Pa. C.S.A. § 908 WHILE
YOU ARE UNDER COURT SUPERVISION. This includes on your person, in your residence or in your vehicle.
4. YOU MUST PAY ANY RESTITUTION, FINES, COSTS AND SUPERVISION FEES during the term of your court supervision.
5. UPON REASONABLE SUSPICION, PROBATION OFFICERS ARE AUTHORIZED TO SEARCH YOU, YOUR VEHICLE AND YOUR HOME WITHOUT
A WARRANT. Any weapons, illegal drugs/paraphernalia, intoxicants and/or contraband in your possession are subject to seizure.
6. YOU MUST NOTIFY THE PROBATION OFFICE IMMEDIATELY OF ANY CHANGE OF ADDRESS.
7. YOU MUST MAKE EVERY EFFORT TO OBTAIN AND MAINTAIN EMPLOYMENT - unless you have proof that you are disabled.
8. ABSOLUTELY NO TRAVEL OUTSIDE PENNSYLVANIA IS PERMITTED – without the written permission of your probation officer. Offenders
who need to travel outside Pennsylvania must proceed through the interstate compact. Your probation officer can instruct you in regard
to the interstate compact process.
9. YOU MUST NOTIFY YOUR PROBATION OFFICER AT ONCE IF YOU ARE ARRESTED OR CITED BY THE POLICE. You must also inform the
arresting officer that you are under court supervision.
10. YOU MAY NOT USE OR POSSESS ANY CONTROLLED SUBSTANCES, unless legally prescribed for a legitimate medical or mental health need.
11. YOU ARE SUBJECT TO RANDOM DRUG AND ALCOHOL TESTING when ordered by your probation officer.
12. YOU MUST SUBMIT TO IDENTIFICATION PROCEDURES if requested by your probation officer. This could include fingerprinting,
photographing, DNA or other identification procedures.
13. YOU MAY BE REQUIRED TO UNDERGO AN ASSESSMENT TO DETERMINE YOUR SUPERVISION NEEDS - The probation department has been
granted permission by the Court to require you to engage in any services that our assessment tools indicate are related to your supervision
needs.
14. YOU MAY BE REQUIRED TO PARTICIPATE IN ANY PROGRAM THAT THE PROBATION DEPARTMENT DEEMS NECESSARY IN ORDER TO
ADDRESS AREAS IN YOUR LIFE THAT MAY LEAD TO CRIMINAL BEHAVIOR.
15. IF YOU VIOLATE THE TERMS OF YOUR PROBATION/PAROLE/IP, ARE ARRESTED FOR A NEW OFFENSE OR ARE CONVICTED OF ANOTHER
OFFENSE WHILE UNDER COURT SUPERVISION –your period of supervision may be revoked and you may be sentenced to a new period of
supervision, or a period of incarceration consistent with your recommended sentencing guidelines.
16. YOU MUST COMPLY WITH ANY COURT-IMPOSED SPECIAL CONDITIONS OF PROBATION/PAROLE/IP – examples include no victim contact,
community service, drug & alcohol treatment. Failure to comply with your special conditions of probation/parole is a violation of the terms
of your probation.
17. IF YOU ARE SENTENCED TO A TERM OF INTERMEDIATE PUNISHMENT (INCLUDING ELECTRONIC MONITORING), you may be required to
undergo individual or family counseling; undergo available medical or psychiatric treatment or to enter and remain in a specified institution
for that purpose; be subject to intensive supervision while remaining within the jurisdiction of the court; to participate in drug or alcohol
screening and treatment programs, including inpatient programs; to do other things reasonably related to rehabilitation; or to be subject
to electronic monitoring.
By signing these general conditions and rules of probation/parole/IP, you acknowledge that you have read them or that they have been read to you,
that you understand them, that you have been given an opportunity to ask any questions you have about them and that you have been provided
with a copy of these general conditions and rules of probation/parole/IP.
Signature of Probationer/Parolee
Date
2.1.21
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

IN THE COURT OF COMMON PLEAS OF ALLEGHENY (Fifth Judicial District of Pennsylvania)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 16 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document