200-00362 – Waiver of Further Appearance Request to Enter Plea (06/2020) Page 1 of 3
STATE OF VERMONT
SUPERIOR COURT
CRIMINAL DIVISION
Unit
Docket No.
State of Vermont vs. ___________________________________ DOB: ____________________
Defendant’s Address: _________________________________________________________________
WAIVER OF FURTHER APPEARANCE AND REQUEST TO ENTER PLEA
I, the Defendant named above, am charged with the crime(s) of ___________________________________,
which is a misdemeanor under the laws of the State of Vermont. I understand that the maximum possible
penalty for this offense is _____________________________________.
I understand that the mandatory minimum penalty for this offense : _____________________________
Not Applicable
I understand that the Court can order restitution to a victim, if any.
I understand that in order to prove the charge against me, the State must prove the following essential
elements beyond a reasonable doubt:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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I understand that I have the right to be represented by an attorney at my own expense, and if I cannot afford
to hire one, to have one appointed at State expense.
I am not represented by an attorney and do not wish to be represented by one.
I am represented by an attorney, whose name is _________________________ . I am satisfied with the
advice and representation of my attorney.
I understand that as a defendant in a criminal case I have certain constitutional and statutory rights. I
understand that I may continue to plead NOT GUILTY to the above offense, and that the State has the burden
of proving me guilty beyond a reasonable doubt. I understand that by pleading GUILTY or NOLO CONTENDERE
I am giving up the following rights, and that the Court may impose the same punishment as if I had continued
to plead NOT GUILTY, stood trial, and been convicted by a jury:
a. the right to a trial by jury;
b. the right to question any witnesses testifying against me;
c. the right to present evidence and have witnesses brought to the Court for me at State expense;
d. the right to remain silent regarding the offense with which I am charged;
e. the right to appeal.
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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__________________________________________________________________________________________
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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.
200-00362 – Waiver of Further Appearance Request to Enter Plea (06/2020) Page 3 of 3
I hereby ask the Court to accept my plea to the charge(s) listed above and defer sentencing for a period of
_______________ months/years and issue a Deferred Probation Order imposing as outlined in the
attached Notice of Plea Agreement and attached Deferred 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, during the term of my deferred sentence, if I do not comply with
the terms of this agreement, that the Court may impose sentence up to the maximum penalty outlined
above and any applicable mandatory minimum sentence(s) and Court surcharges. I agree to report to
Probation and Parole no later than __________ AM PM on _______________ to meet with my
Probation Officer.
I ask the Court to accept my plea in writing as appearing personally in Court would pose the following hardship
for me:
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Date
__________________________________ _______________________________________
Signature of Defendant
________________________________________ _______________________________________
Signature of Guardian ad Litem Signature of Attorney
(if defendant is under 18 years of age)
Per Section 5231 of Title 13 of the Vermont Statutes Annotated, the State of Vermont represents that:
there is no victim.
the victim(s) have been given advance notice of the defendant’s change of plea and their right to
personally appear to express reasonably their views concerning the crime, the person convicted, and the
need for restitution. The victim(s) is not present and has not expressed, either orally or in writing, views
regarding sentencing or the proposed deferral of sentencing.
I find that the defendant’s personal appearance would cause a hardship that would outweigh any
advantage and hereby accept the defendant’s plea to the charges listed above, finding it to be voluntary
and made with knowledge and understanding of its consequences after a knowing waiver of constitutional
rights. The plea has a factual basis. I adjudge the defendant guilty and enter a judgment of guilty.
I do not accept the defendant’s plea by waiver for the charge(s) listed above.
Date
__________________________________ _______________________________________
Signature of Judge