Clear Form
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8 UNITED STATES DISTRICT COURT
9 NORTHERN DISTRICT OF CALIFORNIA
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11 UNITED STATES OF AMERICA, No.
Plaintiff,
12 APPLICATION FOR PERMISSION TO
Northern District of California
ENTER PLEA OF GUILTY AND ORDER
United States District Court
v.
13 ACCEPTING PLEA
14 (Fed. R. Crim. P., Rules 10 and 11)
Defendant.
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17 The defendant represents to the Court:
18 1. My full true name is____________________________. I am _____ years of age.
19 I have gone to school up to and including ____________________________. My most
20 recent occupation has been________________________________________. I request that all
21 proceedings against me be in my true name.
22 2. I am represented by a lawyer. His/her name is _____________________________.
23 3. I received and read a copy of the indictment/information. If applicable: An
24 interpreter who speaks_________________ read it to me in ___________________, and I have
25 discussed it with my lawyer.
26 I fully understand every charge made against me. I understand these charges to be as
27 follows:
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3 4. I have told my lawyer all the facts and circumstances known to me about the
4 charges made against me in the indictment/information. I believe that my lawyer is fully informed
5 on all such matters.
6 5. I know that the Court must be satisfied that there is a factual basis for a plea of
7 “GUILTY” before my plea can be accepted. I represent to the Court that I took the following
8 actions in connection with the charges made against me in Count[s] ______________ and that
9 these facts are true and correct:
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Northern District of California
United States District Court
13 6. My lawyer has counseled and advised me on the nature of each charge, all lesser
14 included charges, all penalties and consequences of each charge, all possible defenses that I may
15 have in this case, and constitutional rights I am waiving.
16 7. I understand that my constitutional rights are as follows:
17 (a) the right to plead not guilty or, having already so pleaded, to persist in that plea;
18 (b) the right to a jury trial;
19 (c) the right to represented by counsel – and if necessary have the Court appoint
counsel – at trial and at every other stage of the proceeding; and
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(d) the right at trial to confront and cross-examine adverse witnesses, to testify and
21 present evidence, to compel the attendance of witnesses, to be protected from
compelled self-incrimination, and to remain silent, such that if I do not take the
22 witness stand, no inference of guilt may be drawn from such failure and the jury
must be so advised.
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24 8. I know that I may plead “NOT GUILTY” to any offense charged against me and
25 exercise all of my rights as listed above.
26 9. I know that if I plead “GUILTY,” I am giving up all of the trial rights enumerated
27 in paragraph 7—except my continuing right to counsel—and that there will be no trial either
28 before a court or jury.
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1 10. I know that if I plead “GUILTY,” the result of my plea is more than just an
2 admission or confession of guilt. I understand that it will result in my conviction, and the Court
3 may impose the same punishment as if I had pleaded “NOT GUILTY,” stood trial, and been
4 convicted by a jury.
5 11. My lawyer has informed me that the maximum and minimum, if any, punishments
6 which the law provides for the offense charged in Count(s) __________ are as follows:
7 (For multiple counts, include the following information for each count)
8 (a) Maximum prison sentence: ______ years
9 (b) Mandatory minimum prison sentence (if applicable): ______ years
10 (c) Maximum supervised release term: ______ years
11 (d) Minimum supervised release term (if applicable): ______ years
12 (e) Mandatory special assessment: $__________
Northern District of California
United States District Court
13 (f) Restitution: $__________ (or determined by the Court)
14 (g) Maximum fine equal to the greater of the following:
15 (1) $__________________ (generally $250,000 for a felony, $100,000
16 for a Class A misdemeanor, or $5,000 for a Class B misdemeanor or lower;
17 see 18 U.S.C. § 3571)); or
18 (2) $__________________ (twice the gross pecuniary gain I derived
19 from the offense); or
20 (3) $___________________ (twice the gross pecuniary loss caused by
21 the offense to another person or persons).
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23 If applicable: I acknowledge that pleading guilty may have consequences to my
24 immigration status if I am not a citizen of the United States. Under federal law, a broad range of
25 crimes are removable offenses, and I understand that removable offenses are described in 8 U.S.C.
26 §§ 1101(a)(43) and 1227(a)(2), among other statutes. I have reviewed these statutory provisions
27 with my attorney, who has informed me of the immigration consequences of my guilty plea.
28 Removal and other immigration consequences are the subject of a separate proceeding, however,
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1 and I understand that no one, including my attorney or the district court, can predict to a certainty
2 the effect of this conviction on my immigration status. I nevertheless affirm that I want to plead
3 guilty regardless of any immigration consequences that may result from my guilty plea[s], even if
4 the consequences are my automatic removal from the United States, denial of citizenship of the
5 United States, and/or denial of future admission to the United States.
6 If applicable: I understand that, because I am pleading guilty to more than one count, the
7 Court may order the sentences on those counts to run consecutively.
8 I understand that if I violate any condition of supervised release, the release may be
9 revoked, and I may be sentenced to all or part of the term of supervised release imposed in
10 addition to any other term of imprisonment which I have received. I understand that if I violate
11 any term of probation, the probation may be revoked, and I may be sentenced up to the maximum
12 statutory term of imprisonment for the offense.
Northern District of California
United States District Court
13 I understand that I may be assessed the costs of confinement and/or supervision. I
14 understand I may be ordered to pay restitution in an amount determined by the Court.
15 12. I know that the sentence I will receive will be decided solely by the Judge. I
16 understand that the Judge will make no decision regarding my sentence until the Judge has read
17 and considered the pre-sentence investigation report prepared and submitted to the Court by the
18 Probation Department. I also understand that the Court and counsel cannot promise me now what
19 sentence will be imposed. I understand that in deciding what sentence it will impose, the Court
20 will calculate my sentencing range under the Sentencing Guidelines. I understand that while the
21 Court is not bound to apply the Guidelines, it must take them into consideration when sentencing
22 me, together with the factors set forth in 18 U.S.C. § 3553(a).
23 13. I understand that under provisions of certain criminal statutes, certain property of
24 mine may be forfeited to the United States. I have been advised by my lawyer whether, and to
25 what extent, my property may be subject to forfeiture.
26 14. If I am on probation, supervised release or parole in this or any other Court, I know
27 that by pleading guilty here, my probation, release or parole may be revoked, and I may be
28 required to serve time in that case, which may be consecutive (that is, in addition to) any sentence
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2 15. I declare that no officer or agent of any branch of government (federal, state, or
3 local) has promised or suggested that I will receive a lighter sentence, or probation, or any other
4 form of leniency, nor have any other promises been made if I plead “GUILTY” except as follows:
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8 (In the space above, insert any promises or concessions made to the defendant or to his/her
9 attorney).
10 If anyone else made such a promise or suggestion, except as noted in the previous
11 sentence, I know that it was entirely without authority or effect.
12 16. I believe that my lawyer has done all that a lawyer could do to counsel and assist
Northern District of California
United States District Court
13 me, and I am satisfied with the advice and help he/she has given me.
14 17. I know that the Court will not permit anyone to plead “GUILTY” who maintains
15 he/she is innocent and, with that in mind and because I am “GUILTY,” I respectfully request the
16 Court to accept my plea of “GUILTY” and to have the clerk enter my plea of “GUILTY” as
17 follows:
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21 18. My mind is clear. I am not under the influence of alcohol or drugs, and I am not
22 under a doctor’s care. The only drugs, medicines, or pills that I have taken within the past seven
23 days are:
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27 (If none, so state.)
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1 19. I confirm that my decision to plead guilty is made voluntarily, and no one coerced
2 or threatened me to complete this Application. I offer my plea of “GUILTY” freely and
3 voluntarily and of my own accord, and with full understanding of all the matters set forth in the
4 indictment/information, in this Application, and in the certificate of my lawyer which is attached
5 to this Application. In offering my plea of “GUILTY,” I freely and voluntarily waive (that is, give
6 up) the constitutional rights guaranteed to me as stated in paragraph 7 above — with the exception
7 of my right to counsel.
8 20. I waive the reading of the indictment/information in open court, and I request the
9 Court to enter my plea of “GUILTY” as set forth in Paragraph 17 of this Application.
10 21. I understand that the Court will address me personally in open court to determine
11 the voluntariness of my guilty plea and to establish a factual basis for it. I understand that the
12 Court may place me under oath, and that the government may use any false statements that I make
Northern District of California
United States District Court
13 under oath against me in a prosecution for perjury or false statement (which is a felony).
14 22. ________ I am proficient enough in English to read the above and have read and
15 fully understand it.
16 _________ I am not proficient enough in English to read the above. I speak and
17 understand ____________________, which is my native language. The above was read to me
18 in___________________ and I fully understand it.
19 Signed by me in open court in the presence of my attorney this____ day of____________,
20 20____.
21 ___________________________________________
Defendant
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1 CERTIFICATE OF COUNSEL
2 I have fully explained to my client the charges in the indictment/information in the case,
3 the defenses he/she may have to the charges, all of the information set forth in this Application,
4 and all the rights that a criminal defendant has. In my opinion, my client understands the charges,
5 the defenses, the information in this Application, and the rights he or she is giving up by pleading
6 guilty, and, based on the information now known to me, his/her decision to plead guilty is
7 knowing and voluntary Signed by me in open court in the presence of the above-named defendant
8 after a full discussion of the contents of this certificate with the defendant this________ day
9 of____________, 20___ .
10 ______________________________________
Attorney for the Defendant
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Northern District of California
United States District Court
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14 INTERPRETER CERTIFICATION
15 I, ________________________, hereby certify that I am a certified __________
16 [language] interpreter and that I accurately translated this Application to the defendant, he/she told
17 me that he/she understood it, and I am satisfied that his/her answer is true and correct.
18 Date__________________________ _____________________________________
Interpreter’s Signature
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1 ORDER
2 I find that:
3 1. The defendant enters this plea of guilty freely and voluntarily and not out of
4 ignorance, inadvertence, fear, or coercion.
5 2. The defendant understands and knowingly, freely, and voluntarily waives his/her
6 constitutional rights.
7 3. The defendant freely and voluntarily executed the attached Application and fully
8 understands its contents.
9 4. The defendant has admitted the essential elements of the crime charged.
10 IT IS THEREFORE ORDERED that the defendant’s plea of “GUILTY” entered in open
11 court be accepted and entered as requested in this Application and as recommended in the
12 certificate signed by the defendant’s lawyer.
Northern District of California
United States District Court
13 Done in open court this_____ day of____________, 20____.
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15 ______________________________________
United States District Judge
16 Northern District of California
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