Fill and Sign the Statement Plea Form

Court of Washington for Plaintiff, v. Defendant. No . Statement of Defendant on Plea of Guilty 1. My true name is ________________________________________. 2. My age is _______________. 3. The last level of education I completed was: ____________________. 4. I Have Been Informed and Fully Understand that : (a) I have the right to representation by a lawyer and that if I cannot afford to pay for a lawyer, one will be provided at no expense to me. (b) I am charged with: Count Crime RCW or Ordinance (with subsection) 1 . 2 . 3 . 4 . [ ] In count(s) _________, the defendant committed the offense against another family or household member as defined in RCW 10.99.020. The elements are: [ ] as set out in the charging document. [ ] as follows: Statement of Defendant on Plea of Guilty - Page 1 of 7 CrRLJ-04.0200 (08/2017) - CrRLJ 4.2(g) . 5. I Understand That I Have the Following Important Rights, and I Give Them All Up by Pleading Guilty : (a) The right to a speedy and public trial by an impartial jury in the county where the crime is alleged to have been committed; (b) The right to remain silent before and during trial, and the right to refuse to testify against myself; (c) The right at trial to hear and question the witnesses who testify against me; (d) The right at trial to testify and to have witnesses testify for me. These witnesses can be made to appear at no expense to me; (e) I am presumed innocent unless the charge is proven beyond a reasonable doubt or I enter a plea of guilty; (f) The right to appeal a finding of guilt after a trial. 6. In Considering the Consequences of My Guilty Plea, I Understand That : (a) My right to appeal is limited. (b) The crime with which I am charged carries a maximum sentence of _______ days in jail and a $_____________ fine. (c) The prosecuting authority will make the following recommendation to the judge: . (d) The judge does not have to follow anyone’s recommendation as to sentence. The judge can give me any sentence up to the maximum authorized by law no matter what the prosecuting authority or anyone else recommends. (e) The judge may place me on probation for up to five (5) years if I am sentenced for a domestic violence offense or under RCW 46.61.5055, or up to two (2) years for all other offenses and impose conditions of probation. If the court orders me to appear at a hearing regarding my compliance with probation and I fail to attend the hearing, the term of probation will be tolled until I appear before the court on the record. (f) The judge may require me to pay costs, fees and assessments authorized by law. The judge may also order me to make restitution to any victims who lost money or property as a result of crimes I committed. The maximum amount of restitution is double the amount of the loss of all victims or double the amount of my gain. (g) If I am not a citizen of the United States, a plea of guilty to an offense punishable as a crime under state law may be grounds for deportation, exclusion from admission to the United States, or denial of naturalization pursuant to the laws of the United States. Notification Relating to Specific Crimes : If any of the Following Paragraphs Apply , the Box Should Be Checked and the Paragraph Initialed by the Defendant . Statement of Defendant on Plea of Guilty - Page 2 of 7 CrRLJ-04.0200 (08/2017) - CrRLJ 4.2(g) [ ] (h) The crime of _________________________________ has a mandatory minimum sentence of _____________________ days in jail and $____________ fine plus costs and assessments. The law does not allow any reduction of this sentence. [ ] (i) The crime of prostitution, indecent exposure, permitting prostitution and patronizing a prostitute has a mandatory assessment of $____________. The court may reduce up to two-thirds of this assessment if the court finds that I am not able to pay the assessment. RCW 9A.88.120. [ ] (j) If this crime involves patronizing a prostitute, a condition of my sentence will be that I not be subsequently arrested for patronizing a prostitute or commercial sexual abuse of a minor. The court will impose crime-related geographical restrictions on me, unless the court finds they are not feasible . If this is my first offense, the court will order me to attend a program designed to educate me about the negative costs of prostitution. [ ] (k) If this crime involves a sexual offense, prostitution, or a drug offense associated with hypodermic needles, I will be required to undergo testing for the human immunodeficiency (HIV/AIDS) virus. [ ] (l) This plea of guilty will result in suspension or revocation of my driving license or privilege by the Department of Licensing for a minimum period of . Department of Licensing may impose a longer period of suspension or revocation based upon my record of conviction. This period may not include suspension or revocation based on other matters. RCW 46.61.5055(9). [ ] (m) I understand that RCW 46.20.265 requires that my driver’s license be revoked if (a) the current offense is a violation under chapters 69.41 [legend drug], 69.50 [violation of the Uniform Controlled Substances Act], or 69.52 [imitation drugs], and I was under the age of 21 at the time of the offense OR (b) the current offense is a violation under RCW 9.41.040 (unlawful possession of firearm), and I was under the age of 18 at the time of the offense OR (c) the current offense is a violation under chapter 66.44 RCW [alcohol], and I was under the age of 18 at the time of the offense, AND if (a), (b), or (c) applies, the court finds that I previously committed an offense while armed with a firearm, an unlawful possession of a firearm offense, or an offense in violation of chapters 66.44, 69.41, 69.50, or 69.52 RCW. [ ] (n) If I am convicted under RCW 26.50.110 for a violation of a domestic violence protection order issued under chapter 26.50 RCW, the court shall impose a mandatory fine of $15. RCW 26.50.110. [ ] (o) I may not possess, own, or have under my control any firearm, and under federal law any firearm or ammunition, unless my right to do so is restored by the court of record that ordered the prohibition on possession of a firearm or the superior court in Washington State where I live, and by a federal court if required. I must immediately surrender any concealed pistol license. [ ] (p) If this crime involves a violation of Title 77 RCW, the Department of Fish and Wildlife may, and in some cases shall, suspend or revoke my privileges under Fish and Wildlife licensing. Statement of Defendant on Plea of Guilty - Page 3 of 7 CrRLJ-04.0200 (08/2017) - CrRLJ 4.2(g) [ ] (q) If this crime involves a drug offense, my eligibility for state and federal education benefits will be affected. 20 U.S.C. § 1091(r). [ ] (r) This plea of guilty is considered a conviction under RCW 46.25.010 and I will be disqualified from driving a commercial motor vehicle. RCW 46.25.090. I am required to notify the Department of Licensing and my employer of this guilty plea within 30 days after the judge signs this document. RCW 46.25.030. [ ] (s) If this case involves driving while under the influence of alcohol and/or being in actual physical control of a vehicle while under the influence of alcohol and/or drugs, I have been informed and understand that I will be subject to: [ ] the penalties described in the “DUI” Attachment or the “Washington State Misdemeanor DUI Sentencing Attachment.” OR [ ] these penalties: Mandatory minimum sentence:  _________________ days in jail.  _________________days of electronic home monitoring.  $ _______________ monetary penalty.  If 24/7 sobriety program is available, if I have 2 prior offenses, a 6-month period of 24/7 sobriety program monitoring; or 6 months of ignition interlock device requirement; or both.  Comply with the rules and requirements of the Department of Licensing regarding the installation and use of a functioning ignition interlock device on all motor vehicles that I operate.  The Department of Licensing will suspend or revoke my driving privilege for the period of time stated in paragraph 6(l). If I have no prior offenses: instead of the minimum jail term, the judge may order me to serve ___________________ days in electronic home monitoring or ______________ days on 24/7 sobriety program monitoring. If I have prior offense(s):  The judge shall order me to submit to an expanded alcohol assessment and comply with treatment deemed appropriate by that assessment.  If I have one prior offense, instead of mandatory jail and electronic home monitoring, the judge may order me to serve not less than ____ days in jail, and either _____ days of electronic home monitoring or a 120-day period of 24/7 sobriety program monitoring or a 120-day period of ignition interlock device requirement, or both.  If I have two prior offenses, instead of mandatory electronic home monitoring, the judge may order me to serve additional jail time. If the judge orders me to refrain from consuming any alcohol, the judge may order me to submit to alcohol monitoring. I shall be required to pay for the monitoring unless the judge specifies that the cost will be paid with funds from another source. The judge may waive electronic home monitoring or order me to obtain an alcohol monitoring device with wireless reporting technology, if that device is reasonably available, if I do not have a dwelling, telephone service, or any other necessity to operate electronic home monitoring. The judge may waive electronic home Statement of Defendant on Plea of Guilty - Page 4 of 7 CrRLJ-04.0200 (08/2017) - CrRLJ 4.2(g) monitoring if I live out of state, or if the judge determines I would violate the terms of electronic home monitoring. If the judge waives electronic home monitoring, he or she will impose an alternative sentence which may include use of an ignition interlock device, additional jail time, work crew, work camp, or 24/7 sobriety program. I understand that the 24/7 sobriety program is a program which requires tests of my blood, breath, urine or other bodily substances to find out if I have alcohol, marijuana, or any controlled substance in my body. Testing must take place at designated location/s. I may be required to pay the fees and costs for the program. The judge will order as conditions of probation that I (i) shall not drive a motor vehicle without a valid license; (ii) shall not drive a motor vehicle without proof of liability insurance or other financial responsibility; (iii) shall not drive or be in physical control of a motor vehicle with an alcohol concentration of 0.08 or more or a THC concentration of 5.00 nanograms per milliliter of whole blood or higher, within two hours after driving; (iv) shall submit to a breath or blood alcohol test upon the reasonable request of a law enforcement officer; (v) shall not drive a motor vehicle without a functioning ignition interlock device as required by the Department of Licensing. For each violation of the above mandatory conditions, the court shall order my confinement for a minimum of 30 days, which may not be suspended or deferred. For each incident involving a violation, the court shall suspend my license for 30 days. [ ] (t) If this case involves reckless driving and the original charge was driving while under the influence of alcohol and/or being in actual physical control of a vehicle while under the influence of alcohol and/or drugs and I have one or more prior offenses, as defined in RCW 46.61.5055(14), within 7 years; or if the original charge was vehicular homicide (RCW 46.61.520) or vehicular assault (RCW 46.61.522) committed while under the influence of intoxicating liquor or any drug, I have been informed and understand that I will be subject to the penalties for Reckless Driving described in the “DUI” Attachment or the “Washington State Misdemeanor DUI Sentencing Attachment.” [ ] (u) If this case involves negligent driving in the first degree, and I have one or more prior offenses, as defined in RCW 46.61.5055(14), within 7 years, I have been informed and understand that I will be subject to the penalties for Negligent Driving–1st Degree described in the “DUI” Attachment or the “Washington State Misdemeanor DUI Sentencing Attachment.” [ ] (v) If this case involves a conviction for operating a vehicle without an ignition interlock device under RCW 46.20.740, then my sentence will run consecutive to any sentences imposed under RCW 46.20.750, 46.61.502, 46.61.504, or 46.61.5055. RCW 46.20.740(3). [ ] (w) If this case involves a conviction for tampering with or circumventing an ignition interlock device under RCW 46.20.750, then my sentence will run consecutive to any sentences imposed under RCW 46.20.740(3), 46.61.502, 46.61.504, 46.61.5055, 46.61.520(1), or 46.61.522(1)(b). [ ] (x) If this crime involves sexual misconduct with a minor in the second degree, communication with a minor for immoral purposes, or attempt, solicitation, or Statement of Defendant on Plea of Guilty - Page 5 of 7 CrRLJ-04.0200 (08/2017) - CrRLJ 4.2(g) conspiracy to commit a sex offense, or a kidnapping offense involving a minor, as defined in RCW 9A.44.128, I will be required to register with the county sheriff as described in the “Offender Registration” Attachment. [ ] (y) Pursuant to RCW 43.43.754, if this crime is an offense which requires sex or kidnapping offender registration, or is one of the following offenses: assault in the fourth degree where domestic violence was pleaded and proved, assault in the fourth degree with sexual motivation, communication with a minor for immoral purposes, custodial sexual misconduct in the second degree, failure to register, harassment, patronizing a prostitute, sexual misconduct with a minor in the second degree, stalking, or violation of a sexual assault protection order granted under chapter 7.90 RCW, I will be required to have a biological sample collected for purposes of DNA identification analysis, unless it is established that the Washington State Patrol crime laboratory already has a sample from me for a qualifying offense . [ ] (z) Travel Restrictions : I will be required to contact my probation officer, the probation director or designee, or the court if there is no probation department, to request permission to travel or transfer to another state if I am placed on probation for one year or more and this crime involves: (i) an offense in which a person has incurred direct or threatened physical or psychological harm; (ii) an offense that involves the use or possession of a firearm; (iii) a second or subsequent misdemeanor offense of driving while impaired by drugs or alcohol; (iv) a sexual offense that requires the offender to register as a sex offender in the sending state. I understand that I will be required to pay an application fee with my travel or transfer request. 7. I plead guilty to the crime(s) of as charged in the complaint(s) or citation(s) and notice. I have received a copy of that complaint or citation and notice. [ ] The complaint or citation and notice was orally amended and I waive filing of a written amended complaint or citation and notice. 8. I make this plea freely and voluntarily. 9. No one has threatened harm of any kind to me or to any other person to cause me to make this plea. 10. No person has made promises of any kind to cause me to enter this plea except as set forth in this statement. 11. Statement of Facts : The judge has asked me to state in my own words what I did that makes me guilty of the crime(s). This is my statement (state the specific facts that support each element of the crime(s)): . [ ] I committed this crime against a family or household member as defined in RCW 10.99.020. [ ] Instead of making a statement, I agree that the court may review the police reports Statement of Defendant on Plea of Guilty - Page 6 of 7 CrRLJ-04.0200 (08/2017) - CrRLJ 4.2(g) and/or a statement of probable cause supplied by the prosecution to establish a factual basis for the plea. 12. My lawyer has explained to me, and we have fully discussed, or I have read, all of the above paragraphs. I understand them all. I have been given a copy of this “Statement of Defendant on Plea of Guilty.” I have no further questions to ask the judge. Date: Defendant I have read and discussed this statement with the defendant and believe that the defendant is competent and fully understands the statement. Prosecuting Authority Defendant's Lawyer Type or Print Name WSBA No. Type or Print Name WSBA No. The foregoing statement was signed by the defendant in open court in the presence of the defendant’s lawyer, if represented, and the undersigned judge. The defendant asserted that (check the appropriate box): [ ] (a) The defendant had previously read; or [ ] (b) The defendant’s lawyer had previously read to him or her; or [ ] (c) An interpreter had previously read to the defendant the entire statement above and that the defendant understood it in full. In t erpreter Declaration : I am a certified or registered interpreter, or have been found otherwise qualified by the court to interpret in the ____________________________ language, which the defendant understands. I have translated this document for the defendant from English into that language. I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Signed at (city) ____________________, (state) ____________, on (date) _________________. _______________________________________ ____________________________________ Interpreter Print Name I find the defendant’s plea of guilty to be knowingly, intelligently, and voluntarily made. Defendant understands the charges and the consequences of the plea. There is a factual basis for the plea. The defendant is guilty as charged. Dated: _____________________________ Judge Statement of Defendant on Plea of Guilty - Page 7 of 7 CrRLJ-04.0200 (08/2017) - CrRLJ 4.2(g)