Pennsylvania Bulletin

PA Bulletin, Doc. No. 01-395b

[31 Pa.B. 1326]

[Continued from previous Web Page]

CARBON COUNTY
MAGISTERIAL DISTRICT No.

Dear Sir:

   You have been summoned to appear for a preliminary hearing at
_________________  on _________________ , in the Office of _________________ .

   Enclosed please find the following forms:

1. Criminal Complaint and Arrest Warrant Affidavit

2. Notice of Hearing

3. Carbon County Public Defender Guidelines

4. Application for ARD Program (Accelerated Rehabilitation Program) if you are eligible

5. Prior Criminal Record Statement

   Examine the enclosed Carbon County Public Defender Guidelines. If you feel you are eligible, call the Public Defender's Office immediately to set up an appointment to fill out an application. The Public Defender's Office is located in the Carbon County Courthouse, Jim Thorpe, Pennsylvania. The telephone number is 570-325-2343.

   You should have either obtained an attorney or had a Public Defender assigned to you before your preliminary hearing. This attorney should be present with you at your preliminary hearing.

   If this is your first criminal offense, you may be eligible for the ARD program. Enclosed are the ARD guidelines used in Carbon County. If you meet the guidelines, you should fill out the enclosed application for the ARD program and Prior Criminal Record Statement and forward or bring both to the Preliminary Hearing at the District Justice.

Very truly yours,

District Justice

OFFICE OF THE DISTRICT ATTORNEY
CARBON COUNTY COURTHOUSE
P. O. BOX 36
JIM THORPE, PENNSYLVANIA 18229

NOTICE

   Your case MAY be a proper one for handling under the Accelerated Rehabilitative Disposition Program (A.R.D.)

   As you know, you were arrested and charged with a crime. You have the right to a trial and the Commonwealth must prove you are guilty beyond a reasonable doubt. However, you may be helped more by being placed on probation that by being convicted and sentenced to jail, so your case may be chosen for possible inclusion in the Accelerated Rehabilitative Disposition Program. Under this program, instead of being tried, you might be placed on probation immediately. If you stay out of trouble during the period of this program, these charges will be discharged. If you violate the conditions, you will be tried as if you never had been in this program.

   If you desire to be considered for the A.R.D. Program, you must complete the enclosed questionnaire and have the same notarized. When completed, it should be returned to the Office of the District Justice at the time of your preliminary hearing.

   Be advised that applying for admission into the A.R.D. Program does not relieve you of your obligation to appear before the District Attorney's Office or the Court for all scheduled appearances. Failure to so appear will result in a bench warrant being issued for your arrest.

   YOU SHOULD BE CERTAIN TO CONTACT YOUR LAWYER SO THAT YOU UNDERSTAND WHAT THIS PROGRAM IS AND HOW IT WORKS.

Very truly yours,

GARY F. DOBIAS
District Attorney

Enclosure

APPROVED:  ______
DISAPPROVED:  ______
DATE:  ______

OFFICE OF THE DISTRICT ATTORNEY
CARBON COUNTY COURTHOUSE
P. O. BOX 36
JIM THORPE, PENNSYLVANIA 18229
(570) 325-2718

COMMONWEALTH OF PENNSYLVANIA :

:

VS. :          NO.

:

QUESTIONNAIRE TO DETERMINE ELIGIBILITY
FOR ACCELERATED REHABILITATIVE DISPOSITION

TO THE DEFENDANT:

   The following questions are to be answered truthfully and fully under oath or affirmation and returned to the District Justice's Office to enable the District Attorney to determine your eligibility for consideration for Accelerated Rehabilitative Disposition.

   YOU ARE ADVISED THAT ANY FALSE STATEMENT GIVEN IN ANSWER TO ANY QUESTION MADE WITH INTENT TO MISLEAD THE DISTRICT ATTORNEY'S OFFICE IS PUNISHABLE AS A MISDEMEANOR OF THE SECOND DEGREE PUNISHABLE BY A FINE NOT EXCEEDING $5,000.00 AND IMPRISONMENT NOT EXCEEDING TWO (2) YEARS, OR BOTH.

WRITE CLEARLY AND IN INK

1. State your full name, Social Security Number and Driver's Operating Number.

__________

2. What is your date of birth and current age?  __________

3. Give your place of birth (city, state, and country). __________

4. State any other names by which you are known or by which you have been known, including aliases.  __________

5. State any nicknames by which you are known.  __________

6. What is your present address and telephone number?  __________

__________

7. What is your marital status?  __________

8. What is the name of your spouse?  __________

9. Give the names and ages of any children.  __________

__________

10. Give the names of all persons with whom you live and your relationship with each.

__________

__________

__________

11. Give each and every address where you resided during the last five-year period.

__________

__________

__________

12. State your educational experience, giving the names of schools you attended and the date of attendance.

Grade School:  __________

High School:  __________

College:  __________

Other:  __________

13. State your military status. (Check One)

Veteran  ______                           Non-Veteran  ______

If you have been in the military service of the United States, state which branch, the years of service and the type of discharge.

Branch:  ______                              Years:  ______

Discharge:   Honorable:  ______   Dishonorable:  ______

Other:  ______      Explain:  __________

14. State what occupations or jobs you have held in the last five (5) years:

   Employer                              Job Description                              Years

__________

__________

__________

15. What is your present occupation or employment and how long employed?

__________

Employer:  __________

Describe Duties:  __________

If unemployed, source of income:  __________

16. What is your present average net income?  __________

17. What is your ability to pay Court costs? AMT:  __________

18. Have you been arrested for any Juvenile or Adult criminal offenses?

Yes  ______                  No  ______

If so, state the following, using additional sheet if necessary.

Date of Arrest (Month/Year):  __________

Charge:  __________

Jurisdiction (City & State):  __________

Sentence or other Disposition:  __________

19(a). Have you ever been convicted of DUI or been placed on an A.R.D. Program as a result of a DUI Charge?      Yes  ______      No  ______

If so, state:
Date of Arrest:  __________

Date of conviction or acceptance in the A.R.D. Program:  __________

County where this occurred:  __________

19(b). Have you ever been placed in an A.R.D. Program for a non-DUI offense?

Yes  ______      No  ______

If so, state:
Date of Arrest:  __________

Charge:  __________

Date of conviction or acceptance in the A.R.D. Program:  __________

County where this occurred:  __________

20. Are you presently on parole or probation?  __________

21. Have you ever been treated for mental illness or hospitalized for mental illness:

Yes  ______      No  ______

If so, state when, where and period of time.

__________

22. Do you have any disease or other disability at the present time?

Yes  ______      No  ______

If so, state the nature thereof:  __________

__________

23. Are you presently dependent upon or addicted to alcohol or drugs?

Yes  ______      No  ______

24. Are you presently enrolled in any treatment program for alcohol or drug addiction dependency?

Yes  ______      No  ______

THE FOLLOWING QUESTIONS ARE TO BE ANSWERED BY ANY PERSON CHARGED WITH DUI

25. Were you involved in an accident?      Yes  ______      No  ______
If so:

(a)   Do you have insurance? Provide the name of your insurance company.

__________

(b)  Was any person, other than yourself injured?      Yes  ______      No  ______

(c)  If so, give the name and address of injured party or parties, along with a description of the injuries suffered.

__________

(d)  Is there any restitution due? If any, approximately how much?

__________

26. State any other offenses you were charged with, either under the vehicle code or the crimes code, which arose from this incident.

__________

__________

27. What was your blood alcohol reading?  ______

28. WHERE were you drinking?  __________

How long?  __________

TO BE COMPLETED BY ALL APPLICANTS

29. State the name, address and telephone number of three reputable citizens, not related to you, who are willing to support your consideration for the Accelerated Rehabilitative Disposition Program:

NAME                              ADDRESS                              TELEPHONE NUMBER

__________

__________

__________

30. State briefly why you feel you should be given the benefit of placement in the Accelerated Rehabilitative Disposition Program.

   I, hereby, swear to (or affirm) the truth of the facts set forth in this application for Accelerated Rehabilitative Disposition, and I fully realize that an intentionally falsification as to any answer or part thereof is a crime punishable by law.

__________
Signature of Applicant

Acknowledgement:
Sworn to (affirm) and subscribe to
before me this  ______  day of
_________________ , 2000, A.D.
___________________________
NOTARY

COMMONWEALTH OF PENNSYLVANIA : IN THE COURT OF COMMON PLEAS

: CARBON COUNTY, PENNSYLVANIA

            VS. :

: NO.

GUILTY PLEA COLLOQUY

   You are present before this Court because you or your lawyer have stated that you wish to plead guilty to some or all of the criminal offenses with which you have been charged. Please answer fully all the questions on this document. If you do not understand any explanations given to you on this document, say so by putting the word ''no'' in the blank provided after the questions. If you do understand the questions, you should write in the word ''yes''. None of the lines should be left blank.

   After you have finished reading this and filling it out, you should sign it on the last page, on the line that says ''Defendant''. You should also initial each page at the bottom, but only if you have read and have understood that page. If there is anything that you do not understand, you should say so in writing on this form. You should also tell your lawyer and the Judge who hears your case, so that they can explain it to you fully, to make sure you understand all your rights.

   Most of these questions are designed to be answered ''yes'' or ''no''. Where general information is asked for, however, please answer fully.

1. What is your full name?

__________

2. Are you known by any other name or alias?

__________

3. If the answer to Number 2 is ''yes'' state the other name or aliases.

__________

4. What is your date of birth?

__________

5. What was the last grade completed in school?

__________

______
INITIAL

6. Can you read, write and understand the English language?

__________

7. Have you ever been a patient in a mental institution or have you ever been treated for a mental illness?

__________

8. If the answer to Number 7 is ''yes'', please explain the details.

__________

9. Are you currently being treated for a mental illness?

__________

10. If the answer to Number 9 is ''yes'', explain the details.

__________

__________

11. If you are presently being treated for a mental illness, do you feel that you have sufficient mental capacity to understand what you are doing today, and to understand these questions and answer them correctly?

__________

12. Do you understand that you are here today to enter a guilty plea to some or all of the charges against you?

__________

13. Do you understand the nature of the offenses to which you are pleading guilty?

__________

14. Has your lawyer explained to you the elements of the criminal offenses to which you are pleading?  __________

15. Do you admit to committing the offenses to which you are pleading guilty and to the legal elements explained to you making up those offenses?

__________

16. Do you understand that you have a right to a trial by jury?

__________

______
INITIAL

17. Do you understand that the right to trial by jury means that you can participate in the selection of a jury with your attorney; that the jury is randomly selected from the voter registration list of Carbon County and a cross-section of the citizens of Carbon County, and that the jury has to agree unanimously on your guilt before you can be convicted of the offenses with which you are charged?  __________

18. Do you understand that you are presumed innocent until found guilty? In other words, do you understand that the Commonwealth must prove your guilt beyond a reasonable doubt before you can be convicted of the offenses charged?  __________

19. Do you understand that the Commonwealth has the burden of proving you guilty beyond a reasonable doubt, which means you can remain silent and nothing can be held against you for refusing to testify in your own defense?  __________

20. Do you understand that you have a right to confront and cross-examine all Commonwealth witnesses in your case who are necessary to prove your guilt?

__________

21. Do you understand that by pleading guilty you are waiving that right of confrontation and cross-examination?

__________

22. Do you realize that by pleading guilty you are giving up your right to present any pre-trial motions for consideration to this or a higher Court in the event those motions are denied?  __________

23. Do you realize that if you were convicted after a trial you could appeal the verdict to a higher Court and raise any errors that were committed in the trial Court, and that this could result in your being awarded a new trial or discharged, and that by pleading guilty you are giving up this right?

__________

24. Do you realize that if you were convicted after a trial you could appeal the verdict to a higher Court and you could also challenge whether the Commonwealth had presented enough evidence to prove you guilty beyond a reasonable doubt?  __________

______
INITIAL

25. Are you aware that the Court is not bound by the terms of any plea agreement entered into between you, your counsel and the Attorney for the Commonwealth, until the Court accepts such plea agreement?

__________

26. Do you understand that the Court is not a party to any agreement or recommendation made by the parties and that any recommendation and/or stipulation regarding sentence is not binding on the Court and you knowingly waive the right to withdraw this plea if the Court does not concur in the recommended sentence?  __________

27. Are you aware of the permissible range of sentence and/or fines that can be imposed for the offenses to which you are pleading guilty?

__________

28. Are you aware of the maximum sentence and/or fine which the Court could impose upon you for each of the offenses to which you are pleading guilty?  __________

29. Do you understand that any sentence imposed upon you for any of the offenses to which you are pleading guilty can be imposed consecutively to either (a) any sentence imposed upon you for any other offense for which you are pleading guilty in this case; or (b) any sentence imposed upon you in any other case?  __________

30. Do you understand that ''consecutive'' sentences means that one sentence will follow after another and that ''consecutive'' sentences do not run at the same time?  __________

31. Do you understand that the aggregate maximum sentence you could receive if you are pleading guilty to multiple offenses is the total of all maximum sentences for all the offenses added together?

__________

32. Do you understand that you have a right to have witnesses present at your guilty plea hearing to testify for you? Are you willing to give up that right and have the Attorney for the Commonwealth summarize the facts against you?  __________

______
INITIAL

33. After you enter your guilty plea and it is accepted by the Court, you still have a right to appeal your conviction. The appeal from a guilty plea is limited, however, to four grounds. They are:

(a)  that you guilty plea was not knowing, intelligent and voluntary;

(b)  that the Court did not have jurisdiction to accept your plea (in other words, the offenses for which you are pleading guilty did not occur in Carbon County);

(c)  that the Court's sentence is beyond the maximum penalty authorized by law; and

(d)  that your attorney was incompetent in representing you and advising you to enter a plea of guilty

Do you understand these four areas of appeal and what they mean?

__________

      In order to appeal your conviction by a plea of guilty, you must within ten (10) days file a written motion to withdraw your guilty plea and state any of the four above grounds as the basis for your petition to withdraw your guilty plea. This must be done within ten (10) days from the date you are sentenced. If you cannot afford a lawyer to represent you or you are contending that your attorney, who represented you at your guilty plea, was incompetent, you have the right to have other counsel appointed for you to raise those four claims. If your petition to withdraw your guilty plea is denied, you then have thirty (30) days to file an appeal from that denial with the Superior Court of Pennsylvania.

      If you do not file your petition within ten (10) days of your sentence or do not file a Notice of Appeal to the Superior Court within thirty (30) days after your petition to withdraw your guilty plea is denied, you give up your right to ever complain again of any of those four areas, including incompetent counsel.

      Do you understand the meaning of the various appeal rights that have just been explained to you?  __________

34. Has anybody forced you to enter this plea of guilty?

__________

______
INITIAL

35. Are you doing this of your own free will?

__________

36. Have any threats been made to you to enter a plea of guilty?

__________

37. Have any promises been made to you to enter a plea of guilty other than any plea agreement that has been negotiated for you by your attorney?

__________

38. Do you understand that the decision to enter a guilty plea is yours and yours alone; that you do not have to enter a plea of guilty and give up all your rights, as previously explained to you and that no one can force you to enter a guilty plea?  __________

39. Do you understand that if your plea is accepted by this Honorable Court, you would have the right to have a Pre-Sentence Report prepared on your behalf to aid the Judge in determining the appropriate sentence to be imposed upon you? Since this is a plea bargain, are you willing to waive the preparation of the pre-sentence investigation?

_________________  (if applicable)

40. Are you presently on probation or parole?  __________

41. If you are on probation or parole, do you realize that your plea of guilt will mean a violation of that probation or parole and you can be sentences to prison as a result of that violation caused by your guilty plea today?

__________

42. Are you satisfied with the representation of you attorney?

__________

43. Have you had ample opportunity to consult with your attorney before reading this document and entering your plea of guilty?

__________

______
INITIAL

44. Has your attorney gone over with you the meaning of the terms in this document?  __________

   I affirm that I have read the above document in its entirety and I understand its full meaning, and I am still nevertheless willing to enter a plea of guilty to the offenses specified. I further affirm that my signature and initials on each page of this document are true and correct.

__________
Defendant

   I,  _________________ , Esquire, Attorney for  _________________ , state that I have advised me client of the contents and meaning of this document; that it is my belief that he/she comprehends and understands that is set forth above; that I am prepared to try this case; and that the defendant understands what he/she is doing by pleading guilty.

__________
Attorney for the Defendant

______
INITIAL

CARBON COUNTY PUBLIC DEFENDER GUIDELINES

The following financial guidelines established by the Public Defender's Office of Carbon County is to be used in determining eligibility for free legal counsel.
An individual may apply for free legal counsel in the following situations:

   --      criminal charges; misdemeanor and felony.

   --      summary cases only when there is a likelihood that the court will impose imprisonment.

   --      parole/probation violation. (individual must reapply)

The following applicants are presumed to be indigent and eligible for free legal representation:

   --      any individual presently detained in a correctional and state hospital facility who do not have asset(s) and is unable to pay for private counsel.

   --      any individual whose GROSS income is below the maximum income level.

A.    In determining the GROSS income of the applicant, criteria to be considered but not limited to the following will include:

1. All income coming into the home: Unemployment, worker's compensation, social security, pensions, stocks, bonds, interest earned, inheritances, rents received, lawsuits, etc. Assets: house(s), property, car(s), etc. We will require proof.

2. If the applicant is married and living with a spouse, both incomes will be considered. Dependant(s) are child(ren) 18 years and younger living with natural parents or are legally adopted. Proof is required. Single parents who claim child(ren) as dependant(s), must be paying support by Court Order or have child(ren) living with him/her. Proof of Court Ordered support is required.

Family Yearly Monthly Weekly

1 $  8,275 $  690 $172

2 11,100 925 230

3 13,925 1,160 290

4 16,750 1,396 349

5 19,575 1,631 407

6 22,400 1,867 466

7 25,225 2,102 525

8 28,050 2,338 584

each additional 2,825 235 54

   If you feel you are eligible, call the Public Defender's Office to set up an appointment to fill out an application. This must be done in person. You must apply at least five (5) days BEFORE your hearing. Please bring with you all paperwork you have received to date and any copies of proof of any and all income as stated above. The phone number is (570) 325-2343. The Public Defender hours are Monday - Friday, 8:30 a.m. to 4:30 p.m. Except holidays. We do not accept applications after 4:00 p.m., since it takes approximately 20 minutes to fill out the application. WE DO NOT ACCEPT ANY COLLECT CALLS.

   DO NOT have alcohol on your breath or look to be under the influence of any substances or you will be asked to return at another date to complete the application. We are not responsible for any delays if you do not call for an appointment or you are asked to come back because you appear to be under the influence of a substance, or have not brought the required copies of any and all proof mentioned above.

   Remember:Statements made on the application for a Public Defender must be true and correct. Any false statements that are made are subject to penalties of 18 Pa.C.S., Section § 4904, relating to unsworn falsification to authorities.

EXHIBIT ''C''

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[31 Pa.B. 1326]

[Continued from previous Web Page]

CARBON COUNTY
MAGISTERIAL DISTRICT No.

OFFICE OF THE DISTRICT ATTORNEY
CARBON COUNTY COURTHOUSE
P. O. BOX 36
JIM THORPE, PENNSYLVANIA 18229

NOTICE

OFFICE OF THE DISTRICT ATTORNEY
CARBON COUNTY COURTHOUSE
P. O. BOX 36
JIM THORPE, PENNSYLVANIA 18229
(570) 325-2718

QUESTIONNAIRE TO DETERMINE ELIGIBILITY
FOR ACCELERATED REHABILITATIVE DISPOSITION

WRITE CLEARLY AND IN INK

GUILTY PLEA COLLOQUY

CARBON COUNTY PUBLIC DEFENDER GUIDELINES

EXHIBIT ''C''

[Continued on next Web Page]

1.	Criminal Complaint and Arrest Warrant Affidavit
2.	Notice of Hearing
3.	Carbon County Public Defender Guidelines
4.	Application for ARD Program (Accelerated Rehabilitation Program) if you are eligible
5.	Prior Criminal Record Statement

1.	State your full name, Social Security Number and Driver's Operating Number.

	__________
2.	What is your date of birth and current age? __________
3.	Give your place of birth (city, state, and country). __________
4.	State any other names by which you are known or by which you have been known, including aliases. __________
5.	State any nicknames by which you are known. __________
6.	What is your present address and telephone number? __________
	__________
7.	What is your marital status? __________
8.	What is the name of your spouse? __________
9.	Give the names and ages of any children. __________
	__________
10.	Give the names of all persons with whom you live and your relationship with each.

	__________
	__________
	__________
11.	Give each and every address where you resided during the last five-year period.

	__________
	__________
	__________
12.	State your educational experience, giving the names of schools you attended and the date of attendance.
	Grade School: __________
	High School: __________
	College: __________
	Other: __________
13.	State your military status. (Check One)
	Veteran ______ Non-Veteran ______
	If you have been in the military service of the United States, state which branch, the years of service and the type of discharge.
	Branch: ______ Years: ______
	Discharge: Honorable: ______ Dishonorable: ______
	Other: ______ Explain: __________
14.	State what occupations or jobs you have held in the last five (5) years:
	Employer Job Description Years

	__________
	__________
	__________
15.	What is your present occupation or employment and how long employed?

	__________
	Employer: __________
	Describe Duties: __________
	If unemployed, source of income: __________
16.	What is your present average net income? __________
17.	What is your ability to pay Court costs? AMT: __________
18.	Have you been arrested for any Juvenile or Adult criminal offenses?
	Yes ______ No ______
	If so, state the following, using additional sheet if necessary.
	Date of Arrest (Month/Year): __________
	Charge: __________
	Jurisdiction (City & State): __________
	Sentence or other Disposition: __________
19(a).	Have you ever been convicted of DUI or been placed on an A.R.D. Program as a result of a DUI Charge? Yes ______ No ______
	If so, state: Date of Arrest: __________
	Date of conviction or acceptance in the A.R.D. Program: __________
	County where this occurred: __________
19(b).	Have you ever been placed in an A.R.D. Program for a non-DUI offense?
	Yes ______ No ______
	If so, state: Date of Arrest: __________
	Charge: __________
	Date of conviction or acceptance in the A.R.D. Program: __________
	County where this occurred: __________
20.	Are you presently on parole or probation? __________
21.	Have you ever been treated for mental illness or hospitalized for mental illness:
	Yes ______ No ______
	If so, state when, where and period of time.

	__________
22.	Do you have any disease or other disability at the present time?
	Yes ______ No ______
	If so, state the nature thereof: __________
	__________
23.	Are you presently dependent upon or addicted to alcohol or drugs?
	Yes ______ No ______
24.	Are you presently enrolled in any treatment program for alcohol or drug addiction dependency?
	Yes ______ No ______

THE FOLLOWING QUESTIONS ARE TO BE ANSWERED BY ANY PERSON CHARGED WITH DUI

25.	Were you involved in an accident? Yes ______ No ______ If so:
	(a) Do you have insurance? Provide the name of your insurance company.

	__________
	(b) Was any person, other than yourself injured? Yes ______ No ______
	(c) If so, give the name and address of injured party or parties, along with a description of the injuries suffered.

	__________
	(d) Is there any restitution due? If any, approximately how much?

	__________
26.	State any other offenses you were charged with, either under the vehicle code or the crimes code, which arose from this incident.

	__________
	__________
27.	What was your blood alcohol reading? ______
28.	WHERE were you drinking? __________
	How long? __________
TO BE COMPLETED BY ALL APPLICANTS
29.	State the name, address and telephone number of three reputable citizens, not related to you, who are willing to support your consideration for the Accelerated Rehabilitative Disposition Program:
	NAME ADDRESS TELEPHONE NUMBER

__________
__________
__________
30.	State briefly why you feel you should be given the benefit of placement in the Accelerated Rehabilitative Disposition Program.

COMMONWEALTH OF PENNSYLVANIA	:	IN THE COURT OF COMMON PLEAS
	:	CARBON COUNTY, PENNSYLVANIA
VS.	:
	:	NO.

1.	What is your full name?

	__________
2.	Are you known by any other name or alias?

	__________
3.	If the answer to Number 2 is ''yes'' state the other name or aliases.

	__________
4.	What is your date of birth?

	__________
5.	What was the last grade completed in school?

	__________
	______ INITIAL
6.	Can you read, write and understand the English language?

	__________
7.	Have you ever been a patient in a mental institution or have you ever been treated for a mental illness?

	__________
8.	If the answer to Number 7 is ''yes'', please explain the details.

	__________
9.	Are you currently being treated for a mental illness?
	__________
10.	If the answer to Number 9 is ''yes'', explain the details.

	__________
	__________
11.	If you are presently being treated for a mental illness, do you feel that you have sufficient mental capacity to understand what you are doing today, and to understand these questions and answer them correctly?

	__________
12.	Do you understand that you are here today to enter a guilty plea to some or all of the charges against you?

	__________
13.	Do you understand the nature of the offenses to which you are pleading guilty?

	__________
14.	Has your lawyer explained to you the elements of the criminal offenses to which you are pleading? __________
15.	Do you admit to committing the offenses to which you are pleading guilty and to the legal elements explained to you making up those offenses?

	__________
16.	Do you understand that you have a right to a trial by jury?

	__________
	______ INITIAL
17.	Do you understand that the right to trial by jury means that you can participate in the selection of a jury with your attorney; that the jury is randomly selected from the voter registration list of Carbon County and a cross-section of the citizens of Carbon County, and that the jury has to agree unanimously on your guilt before you can be convicted of the offenses with which you are charged? __________
18.	Do you understand that you are presumed innocent until found guilty? In other words, do you understand that the Commonwealth must prove your guilt beyond a reasonable doubt before you can be convicted of the offenses charged? __________
19.	Do you understand that the Commonwealth has the burden of proving you guilty beyond a reasonable doubt, which means you can remain silent and nothing can be held against you for refusing to testify in your own defense? __________
20.	Do you understand that you have a right to confront and cross-examine all Commonwealth witnesses in your case who are necessary to prove your guilt?

	__________
21.	Do you understand that by pleading guilty you are waiving that right of confrontation and cross-examination?

	__________
22.	Do you realize that by pleading guilty you are giving up your right to present any pre-trial motions for consideration to this or a higher Court in the event those motions are denied? __________
23.	Do you realize that if you were convicted after a trial you could appeal the verdict to a higher Court and raise any errors that were committed in the trial Court, and that this could result in your being awarded a new trial or discharged, and that by pleading guilty you are giving up this right?

	__________
24.	Do you realize that if you were convicted after a trial you could appeal the verdict to a higher Court and you could also challenge whether the Commonwealth had presented enough evidence to prove you guilty beyond a reasonable doubt? __________
	______ INITIAL
25.	Are you aware that the Court is not bound by the terms of any plea agreement entered into between you, your counsel and the Attorney for the Commonwealth, until the Court accepts such plea agreement?

	__________
26.	Do you understand that the Court is not a party to any agreement or recommendation made by the parties and that any recommendation and/or stipulation regarding sentence is not binding on the Court and you knowingly waive the right to withdraw this plea if the Court does not concur in the recommended sentence? __________
27.	Are you aware of the permissible range of sentence and/or fines that can be imposed for the offenses to which you are pleading guilty?

	__________
28.	Are you aware of the maximum sentence and/or fine which the Court could impose upon you for each of the offenses to which you are pleading guilty? __________
29.	Do you understand that any sentence imposed upon you for any of the offenses to which you are pleading guilty can be imposed consecutively to either (a) any sentence imposed upon you for any other offense for which you are pleading guilty in this case; or (b) any sentence imposed upon you in any other case? __________
30.	Do you understand that ''consecutive'' sentences means that one sentence will follow after another and that ''consecutive'' sentences do not run at the same time? __________
31.	Do you understand that the aggregate maximum sentence you could receive if you are pleading guilty to multiple offenses is the total of all maximum sentences for all the offenses added together?

	__________
32.	Do you understand that you have a right to have witnesses present at your guilty plea hearing to testify for you? Are you willing to give up that right and have the Attorney for the Commonwealth summarize the facts against you? __________
	______ INITIAL
33.	After you enter your guilty plea and it is accepted by the Court, you still have a right to appeal your conviction. The appeal from a guilty plea is limited, however, to four grounds. They are:

	(a) that you guilty plea was not knowing, intelligent and voluntary;

	(b) that the Court did not have jurisdiction to accept your plea (in other words, the offenses for which you are pleading guilty did not occur in Carbon County);

	(c) that the Court's sentence is beyond the maximum penalty authorized by law; and

	(d) that your attorney was incompetent in representing you and advising you to enter a plea of guilty
Do you understand these four areas of appeal and what they mean?

__________
In order to appeal your conviction by a plea of guilty, you must within ten (10) days file a written motion to withdraw your guilty plea and state any of the four above grounds as the basis for your petition to withdraw your guilty plea. This must be done within ten (10) days from the date you are sentenced. If you cannot afford a lawyer to represent you or you are contending that your attorney, who represented you at your guilty plea, was incompetent, you have the right to have other counsel appointed for you to raise those four claims. If your petition to withdraw your guilty plea is denied, you then have thirty (30) days to file an appeal from that denial with the Superior Court of Pennsylvania.

If you do not file your petition within ten (10) days of your sentence or do not file a Notice of Appeal to the Superior Court within thirty (30) days after your petition to withdraw your guilty plea is denied, you give up your right to ever complain again of any of those four areas, including incompetent counsel.

Do you understand the meaning of the various appeal rights that have just been explained to you? __________
34.	Has anybody forced you to enter this plea of guilty?

	__________
	______ INITIAL
35.	Are you doing this of your own free will?

	__________
36.	Have any threats been made to you to enter a plea of guilty?

	__________
37.	Have any promises been made to you to enter a plea of guilty other than any plea agreement that has been negotiated for you by your attorney?

	__________
38.	Do you understand that the decision to enter a guilty plea is yours and yours alone; that you do not have to enter a plea of guilty and give up all your rights, as previously explained to you and that no one can force you to enter a guilty plea? __________
39.	Do you understand that if your plea is accepted by this Honorable Court, you would have the right to have a Pre-Sentence Report prepared on your behalf to aid the Judge in determining the appropriate sentence to be imposed upon you? Since this is a plea bargain, are you willing to waive the preparation of the pre-sentence investigation?
	_________________ (if applicable)
40.	Are you presently on probation or parole? __________
41.	If you are on probation or parole, do you realize that your plea of guilt will mean a violation of that probation or parole and you can be sentences to prison as a result of that violation caused by your guilty plea today?

	__________
42.	Are you satisfied with the representation of you attorney?

	__________
43.	Have you had ample opportunity to consult with your attorney before reading this document and entering your plea of guilty?

	__________
	______ INITIAL
44.	Has your attorney gone over with you the meaning of the terms in this document? __________

A.	In determining the GROSS income of the applicant, criteria to be considered but not limited to the following will include:
	1.	All income coming into the home: Unemployment, worker's compensation, social security, pensions, stocks, bonds, interest earned, inheritances, rents received, lawsuits, etc. Assets: house(s), property, car(s), etc. We will require proof.
	2.	If the applicant is married and living with a spouse, both incomes will be considered. Dependant(s) are child(ren) 18 years and younger living with natural parents or are legally adopted. Proof is required. Single parents who claim child(ren) as dependant(s), must be paying support by Court Order or have child(ren) living with him/her. Proof of Court Ordered support is required.

Family	Yearly	Monthly	Weekly
1	$ 8,275	$ 690	$172
2	11,100	925	230
3	13,925	1,160	290
4	16,750	1,396	349
5	19,575	1,631	407
6	22,400	1,867	466
7	25,225	2,102	525
8	28,050	2,338	584
each additional	2,825	235	54

[31 Pa.B. 1326]

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CARBON COUNTY MAGISTERIAL DISTRICT No.

OFFICE OF THE DISTRICT ATTORNEY CARBON COUNTY COURTHOUSE P. O. BOX 36 JIM THORPE, PENNSYLVANIA 18229

NOTICE

OFFICE OF THE DISTRICT ATTORNEY CARBON COUNTY COURTHOUSE P. O. BOX 36 JIM THORPE, PENNSYLVANIA 18229 (570) 325-2718

QUESTIONNAIRE TO DETERMINE ELIGIBILITY FOR ACCELERATED REHABILITATIVE DISPOSITION

WRITE CLEARLY AND IN INK

GUILTY PLEA COLLOQUY

CARBON COUNTY PUBLIC DEFENDER GUIDELINES

EXHIBIT ''C''

[Continued on next Web Page]

CARBON COUNTY
MAGISTERIAL DISTRICT No.

OFFICE OF THE DISTRICT ATTORNEY
CARBON COUNTY COURTHOUSE
P. O. BOX 36
JIM THORPE, PENNSYLVANIA 18229

OFFICE OF THE DISTRICT ATTORNEY
CARBON COUNTY COURTHOUSE
P. O. BOX 36
JIM THORPE, PENNSYLVANIA 18229
(570) 325-2718

QUESTIONNAIRE TO DETERMINE ELIGIBILITY
FOR ACCELERATED REHABILITATIVE DISPOSITION