STATE OF CONNECTICUT SUPERIOR COURT JUVENILE MATTERS WAIVER OF CHILD/PARENT STATEMENT OF RESPONSIBILITYADDRESS OF COURT JD-JM-29EL Rev. 6-96 CGS 46b-135 to 137, 138a Pr. Bk. Secs. 1025.1, 1048.1DOCKET NO.BIRTHDATENAME AND ADDRESS OF CHILDNAME AND ADDRESS OF PARENT(S) OR GUARDIANWAIVER OF CHILD, in the presence of my (parent(s)/guardian), and havingI,been informed in (his/her/their) presence of my right 1) to counsel, and the Court's obligation to provide counsel if I cannot afford it; 2) to remain silent because my statement may later be used against me; and 3) to be fully informed as to my claimed delinquent behavior as set forth in the Notice to Appear or summons, dateddo hereby for the purpose of this proceeding waive my right to counsel and to remain silent.SIGNATURE OF CHILDSIGNATURE OF PARENT OR GUARDIANDATEWAIVER OF PARENT OR GUARDIANI,, parent/guardian ofhave been informed of my right to counsel and the Court's obligation to provide counsel if I cannot afford it, and my further right to refuse to testify against said child except that a parent or guardian who has received personal violence from said child, may upon trial for such personal violence be compelled to testify. The parent or guardian may refuse to testify if the testimony might tend to incriminate the parent or guardian. I do hereby for the purpose of this proceeding waive my right to counsel and to remain silent.SIGNATURE OF PARENT OR GUARDIANDATE SIGNATURE OF WITNESSSTATEMENT OF RESPONSIBILITY, in the presence of my (parent)(parents)(counsel) admit that I I,am responsible for the following act(s):SIGNATURE OF CHILDDATE SIGNATURE OF PARENT OR GUARDIAN2000 (C) American LegalNet, Inc.
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