In the Court of Common Pleas of ___________________ County
_________________________ :
: Case number: ________________
:
vs. :
:
_________________________ :
:
Interpreter Waiver Form
Name of party waiving the services of an interpreter: _________________________________________
(Print name)
Relationship to case: Defendant/Respondent Plaintiff/Petitioner Witness Victim
(Check one)
Parent/Person in loco parentis Other: ______________________________
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
__________________________________________ ____________________________________
Interpreter signature Date
___________________________________
By the court
AOPC / ICP – 029 5/26/2010
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