CHINS Waiver Of Counsel {NHJB-2841-DF}

THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) CHINS WAIVER OF COUNSEL I, of have been alleged to be a Child in Need of Services with the offense of before said Court. I have had explained to me at the initial appearance (my first court hearing) my right to be represented by an attorney. I understand that if I or my parents, guardian or custodian are unable to afford any attorney, the Court will appoint one to represent me. I have had the allegations against me fully explained. If the Court finds I am a child in need of services, consequences may include: placement on conditional release; attendance at individual or family counseling; release in the care and supervision of a relative, group home, or crisis home; uncompensated community service; attendance at an after-school or evening program; the payment of a fine up to $250; payment of restitution; and/or loss or denial of driver's license for a minimum of 90 days but not more than a year. I understand what I am doing. I DO NOT want an attorney and hereby waive (give up) my right to have an attorney represent me. Signature of Child Date Signature of Parent/Guardian/Custodian The undersigned Judge, having asked the child if s/he understands the charge(s) against him/her and the possible penalties which the Court may order, is satisfied that s/he fully understands his/her right to have an attorney represent him/her and, if indigent, to have an attorney appointed by the Court. The Court discussed the matter of court-appointed counsel with the child's parents, guardian or custodian. His/her parents, guardian or custodian concur in this waiver. Based upon this inquiry, the Court believes the child does not have a cognitive, emotional, learning or sensory disability and finds that the child has the mental capacity to evaluate his/her right to an attorney and that the child does knowingly, intelligently and voluntarily waive that right. Date Signature of Judge Printed Name of Judge NHJB-2841-DF (09/03/2013) Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com