200-00362 – Waiver of Further Appearance Request to Enter Plea (06/2020) Page 2 of 3
No threats or force have been used against me by anyone to try to make me plead guilty or nolo contendere. I
plead guilty or nolo contendere of my own choice, freely and voluntarily. No promises have been made to me
by anyone for the State except those which are contained in the attached Notice of Plea Agreement. I agree
that there is a factual basis for my plea of guilty or nolo contendere, supported by the affidavit and as outlined
in the recitation of facts below.
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I understand that by pleading GUILTY I admit that I committed the essential parts of the offense(s) with which
I have been charged. I understand that by pleading NOLO CONTENDERE I do not deny that I committed the
essential parts of the charge(s). I further understand that a plea of GUILTY or NOLO CONTENDERE to a
violation of Title 23 of the Vermont Statutes Annotated may result in a suspension of my license or privilege to
operate a motor vehicle in the State of Vermont. I understand that, a plea of GUILTY or NOLO CONTENDERE
may have certain collateral consequences. I have reviewed the Notice of Potential Collateral Consequences of
a Conviction on the reverse side of the attached plea agreement. I further understand that, if I am not a
citizen of the United States, a plea of GUILTY or NOLO CONTENDERE may have consequences of
deportation, denial of United States citizenship, or denial of re-entry to the United States.
I hereby ask the Court to accept my plea of ☐ GUILTY ☐ NOLO CONTENDERE to the charge(s) listed above. In
making this request, I waive my statutory rights pursuant to V.R.Cr.P. 32 and do not wish to make a statement
on my behalf or present any information relevant to sentencing or to have my attorney speak of my behalf.
There has been no presentence investigation report in my case.
☐ I enclose $__________ in a check or money order payable to the Superior Court of Vermont for payment
of the fine imposed by the Court, plus the applicable mandatory Court surcharges as recommended in the
attached Notice of Plea Agreement.
☐ I hereby ask the Court to accept my plea to the charge(s) listed above and issue a Sentencing Mittimus
imposing a sentence of _______________ to _______________ days to serve on pre-approved furlough
work crew. I understand that failure to complete this sentence as a pre-approved work crew may result in
my serving the remainder of my sentence in prison. I understand that the Court will also impose a
mandatory Court surcharge for each charge to which I have pled GUILTY or NOLO CONTENDERE. I agree to
report to Probation and Parole no later than __________ ☐ AM ☐ PM on _______________ to
schedule this sentence.
☐ I hereby ask the Court to accept my plea to the charge(s) listed above and issue a Probation Order
imposing a sentence(s) outlined in the attached Notice of Plea Agreement and attached Probation Order. I
have reviewed all applicable standard and special conditions of probation, based on my signature to that
document, agree to those applicable conditions I understand that the Court will also impose a mandatory
Court surcharge for each charge to which I have pled GUILTY or NOLO CONTENDERE. I understand that,
during the term of my probation, if I do not comply with the applicable standard and special conditions of
probation, that the Court may impose sentence up to the underlying sentence outlined in the attached
Notice of Plea Agreement and attached Probation Order. I agree to report to Probation and Parole no
later than __________ ☐ AM ☐ PM on _______________to meet with my Probation Officer.
