2. My age is .

     3. I went through the grade.

     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:

     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) The crime with which I am charged carries a maximum sentence of days in jail and a $ fine.

     (b) The prosecuting authority will make the following recommendation to the judge:

	.

     (c) 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.

     (d) The judge may place me on probation for up to five years if I am sentenced under RCW 46.61.5055 or up to two 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.

     (e) 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.

     (f) If I am not a citizen of the United States, a plea of guilty to an offense punishable as a crime under state law is 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.

     [ ] (g) 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.

     [ ] (h) 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 (AIDS) virus.

     [ ] (i) This plea of guilty will result in suspension or revocation of my driving license or privilege by the Department of Licensing for a period of . This period may not include suspension or revocation based on other matters.

     [ ] (j) I understand that I may not possess, own, or have under my control any firearm unless my right to do so is restored by a superior court in Washington State, and by a federal court if required. I must immediately surrender any concealed pistol license. RCW 9.41.040.

     [ ] (k) If this crime involves a drug offense, my eligibility for state and federal education benefits will be affected. 20 U.S.C. § 1091(r).

     [ ] (l) 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

     [ ] these penalties: The mandatory minimum sentence of days in jail, days of electronic home monitoring and $ monetary penalty. The court shall require me to apply for an ignition interlock driver's license and to drive only with a functioning ignition interlock device or, if the court waives those requirements, to submit to alcohol monitoring, for ____ year(s). I may also be required to drive only motor vehicles equipped with an ignition interlock device as imposed by the Department of Licensing and/or the court. My driving privilege will be suspended or revoked by the Department of Licensing for the period of time stated in paragraph 6(i). In lieu of the minimum jail term, the judge may order me to serve days in electronic home monitoring. If I do not have a dwelling, telephone service, or any other necessity to operate electronic home monitoring, if I live out of state, or if the judge determines I would violate the terms of electronic home monitoring, the judge may waive electronic home monitoring and impose an alternative sentence which may include additional jail time, work crew or work camp.

     [ ] (m) I understand that if this crime involves sexual misconduct with a minor in the second degree, communication with a minor for immoral purposes, or attempt, solicitation or conspiracy to commit a sex offense, or a kidnapping offense involving a minor, as defined in RCW 9A.44.130, I will be required to register with the county sheriff as described in the "Offender Registration" Attachment.

     [ ] (n) 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 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.

     [ ] (o) Travel Restrictions: I understand that 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.

     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)):

	.

     [ ] Instead of making a statement, I agree that the court may review the police reports 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, 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 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.

     Interpreter Declaration: I am a certified interpreter or have been found otherwise qualified by the court to interpret in the ____________________________ language, which the defendant understands, and I have translated this document for the defendant from English into that language. The defendant has acknowledged his or her understanding of both the translation and the subject matter of this document. 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
Case Name:				Cause No.:

     "DUI" Attachment: Driving under the influence of alcohol and/or actual physical control of a vehicle while under the influence of alcohol and/or drugs. (If required, attach to Statement of Defendant on Plea of Guilty.)

     Court - DUI Sentencing Grid (RCW 46.61.5055 as amended through January 1, 2009)

BAC Result < .15 or No Test Result	No Prior Offense1	One Prior Offense1	Two or Three Prior Offenses1
Mandatory Minimum/ Maximum Jail Time2	24 Consecutive Hours/365 Days	30/365 Days	90/365 Days
EHM2	15 Days in Lieu of Jail	60 Days Mandatory	120 Days Mandatory
Mandatory Minimum/ Maximum Fine3	$865.50/$5,000	$1,120.50/$5,000	$1,970.50/$5,000
Driver's License	90-Day Suspension	2-Year Revocation	3-Year Revocation
II Driver's License* II Device	Required	Required	Required
Alcohol/Drug Ed. or Treatment	As Ordered	As Ordered	As Ordered

*See Court and Department of Licensing (DOL) Ignition Interlock Requirements, page 4.

BAC Result ≥.15 or Test Refusal	No Prior Offense1	One Prior Offense1	Two or Three Prior Offenses1
Mandatory Minimum/ Maximum Jail Time2	2 Consecutive/365 Days	45/365 Days	120/365 Days
EHM2	30 Days in Lieu of Jail	90 Days Mandatory	150 Days Mandatory
Mandatory Minimum/ Maximum Fine3	$1,120.50/$5,000	$1,545.50/$5,000	$2,820.50/$5,000
Driver's License	1-Year Revocation 2 Years if BAC refused	900-Days Revocation 3 Years if BAC refused	4-Year Revocation
II Driver's License* II Device	Required	Required	Required
Alcohol/Drug Ed. or Treatment	As Ordered	As Ordered	As Ordered

*See Court and Department of Licensing (DOL) Ignition Interlock Requirements, page 4.

Court Ordered Ignition Interlock Driver's License and Device Requirements, RCW 46.20.720(2), 46.61.5055(5), 46.20.385, effective January 1, 2009*
Requirement	No Previous Restriction+	Previous 1-Year Restriction+	Previous 5-Year Restriction+
II Driver's License II Device	1 Year	5 Years	10 Years

+Period of time for ignition interlock restriction is pursuant to RCW 46.61.5055 (5)(f).

*See Court and Department of Licensing (DOL) Ignition Interlock Requirements, page 4.

Department of Licensing Required Ignition Interlock Device Requirements, RCW 46.20.720(3) June 10, 2004*
Requirement	No Previous Restriction	Previous 1-Year Restriction	Previous 5-Year Restriction
II Device	1 Year	5 Years	10 Years

*See Court and Department of Licensing (DOL) Ignition Interlock Requirements, page 4.

     ¹Prior Offenses: Count all prior offenses where the arrest date of the prior offense occurred within seven (7) years before or after the arrest date on the current offense. RCW 46.61.5055 (14)(b); Seattle v. Quezada, 142 Wn.App. 43, 174 P.3d 129 (Div. 1 2007). "Prior offense" is defined by RCW 46.61.5055 (14)(a) to include-

     -> Original Convictions for the following: (1) DUI (RCW 46.61.502) (or an equivalent local ordinance); (2) Phys. Cont. (RCW 46.61.504) (or an equivalent local ordinance); (3) Veh. Homicide (RCW 46.61.520) or Veh. Assault (RCW 46.61.522) if either committed while under the influence; (4) Equiv. out-of-state statute for any of the above offenses.

     -> Deferred Prosecution Granted for the following: 1) DUI (RCW 46.61.502) (or equivalent local ordinance); (2) Phys. Cont. (RCW 46.61.504) (or equiv. local ordinance); (3) Neg. Driving 1st (RCW 46.61.5249, or equiv. local ord.), if the person was originally charged with DUI or Phys. Cont. (or an equiv. local ord.), or Veh. Hom. (RCW 46.61.520) or Veh. Assault (RCW 46.61.522). See Bremerton v. Tucker, 126 Wn.App. 26, 103 P.3d 1285 (Div. 2 2005); Seattle v. Quezada, 142 Wn.App. 43, 174 P.3d 129 (Div. 1 2007) (a revoked deferred prosecution only counts as one prior offense).

     -> Amended Convictions for the following: If the person was originally charged with DUI or Phys. Cont. or an equivalent local ordinance, or Veh. Homicide (RCW 46.61.520) or Veh. Assault (RCW 46.61.522) (1) Neg. Driving 1st (RCW 46.61.5249), (2) Reckless Driving (RCW 46.61.500), (3) Reckless Endangerment (RCW 9A.36.050), (4) Equiv. out-of-state or local ordinance for the above offenses. See, Walla Walla v. Greene, 154 Wn.2d 722, Ά 14, 116 P.3d 1008 (2005).

     ²Mandatory Jail and Electronic Home Monitoring (EHM): If there are prior offenses within seven (7) years of arrest date, the mandatory jail shall be served by imprisonment for the minimum statutory term and may not be suspended or deferred unless the court finds that imposition of this mandatory minimum sentence would impose a substantial risk to the offender's physical or mental well-being. The mandatory statutory term may not be converted to EHM. Bremerton v. Bradshaw, 121 Wn.App. 410, 88 P.3d 438 (Div. 2 2004). Where there are no prior offenses within seven (7) years of arrest date, the court may grant EHM instead of mandatory minimum jail. If there are prior offenses, the mandatory EHM may not be suspended or deferred unless the court finds that imposition of this mandatory minimum sentence would impose a substantial risk to the offender's physical or mental well-being. RCW 46.61.5055 (1)(a)(i), (2)(a)(i), (3)(a)(i).

     Mandatory Conditions of Probation for any Suspended Jail Time: The individual is not to: (i) drive a motor vehicle without a valid license to drive and proof of financial responsibility (SR 22), (ii) drive while having an alcohol concentration of .08 or more within two (2) hours after driving, (iii) refuse to submit to a test of his or her breath or blood to determine alcohol concentration upon request of a law enforcement officer who has reasonable grounds to believe the person was driving or was in actual physical control of a motor vehicle while under the influence of intoxicating liquor. Except for ignition interlock driver's license and device or alcohol monitoring requirements under RCW 46.61.5055(5), violation of any mandatory condition requires a minimum penalty of 30 days' confinement, which may not be suspended or deferred, and an additional 30-day license suspension. RCW 46.61.5055(11). Courts are required to report violations of mandatory conditions requiring confinement or license suspension to DOL. RCW 46.61.5055.

     ³Mandatory Monetary Penalty: PSEA 1, RCW 3.62.090(1); Alcohol Violators Fee, RCW 46.61.5054; Criminal Justice Funding (CJF) Penalty, RCW 46.64.055 (Note: RCW 3.62.090 (1) and (2) apply to CJF penalty); Criminal Conviction Fee, RCW 3.62.085.

     Felony DUI and Felony Physical Control: Laws of 2006, ch. 73, §§ 1-3 (effective July 1, 2007) created new class C felony crimes of Felony DUI and Felony Physical Control. With four (4) priors within ten (10) years, or one (1) prior conviction of Veh. Homicide or Veh. Assault (see above), a current offense is a Class C Felony punished under Chapter 9.94A RCW. "Within ten (10) years” means that the arrest for the prior offense occurred within ten (10) years of the arrest for the current offense. Laws of 2007, ch. 474 (effective July 1, 2007); RCW 46.61.5055 (13)(c).

     Jurisdiction: Court has five (5) years jurisdiction.

Department of Licensing - DUI Administrative Sanctions and Reinstatement Provisions (As amended through January 1, 2009)

Administrative Sanctions – RCW 46.20.3101
REFUSED TEST	First Refusal Within 7 Years And No Prior Administrative Action Within Past 7 Years*	Second or Subsequent Refusal Within Past 7 Years OR First Refusal And At Least One Prior Administrative Action Within Past 7 Years*
Adult	1-Year License Revocation	2-Year License Revocation
Minor	1-Year License Revocation	2-Year License Revocation Or Until Age 21 Whichever Is Longer
BAC RESULT	First Administrative Action	Second or Subsequent Administrative Action
Adults ≥ 0.08	90-Day License Suspension	2-Year License Revocation
Minors ≥ 0.02	90-Day License Suspension	1-Year License Revocation Or Until Age 21 Whichever Is Longer

*Day for day credit for revocation period already served under suspension, revocation, or denial imposed under RCW 46.61.5055 and arising out of the same incident.--RCW 46.20.3101(4).

Ignition Interlock Driver's License, RCW 46.20.385 (effective January 1, 2009)

May apply for an Ignition Interlock Driver's License upon receiving RCW 46.20.308 notice or upon suspension or revocation. See "Court and Department of Licensing Ignition Interlock Requirements, page 4."

Note: An individual convicted of DUI or physical control will have his/her driving privilege placed in probationary status for five (5) years from the date he/she is eligible to reinstate his/her driver's license (see RCW 46.61.5055 and 46.20.355). An individual granted a deferred prosecution under RCW 10.05.060 will have his/her driving privilege placed on probationary status for five (5) years from the date of the incident, which was the basis for the deferred prosecution (see RCW 46.20.355 and 10.05.060).

Requirements for Reinstatement of Driving Privilege
Suspended License* (RCW 46.20.311)			Revoked License* (RCW 46.20.311)
•	File and maintain proof of financial responsibility for the future with the Department of Licensing as provided in chapter 46.29 RCW (SR 22)	•	File and maintain proof of financial responsibility for the future with the Department of Licensing as provided in chapter 46.29 RCW (SR 22)
•	Present written verification by a company that it has installed the required ignition interlock device on a vehicle owned and/or operated by the person seeking reinstatement	•	Present written verification by a company that it has installed the required ignition interlock device on a vehicle owned and/or operated by the person seeking reinstatement
•	Pay $150 driver's license reissue fee	•	Pay $150 driver's license reissue fee
•	Driver's ability test NOT required	•	Satisfactorily complete a driver's ability test

*If suspension or revocation is the result of a criminal conviction, the driver must also show proof of either (1) enrollment and satisfactory participation in an approved alcohol treatment program or (2) completion of an alcohol information school, as determined by the court and/or treatment agency.

Court and Department of Licensing (DOL) Ignition Interlock Requirements, RCW 46.20.380, 46.20.385 Ignition Interlock Driver's License, RCW 46.20.380, 46.20.385

Eligible to Apply	•	Conviction of violation of RCW 46.61.502 or 46.61.504, involving alcohol
	•	License suspended, revoked, or denied under RCW 46.20.3101
	•	Proof of installed functioning ignition interlock device
Requirements	•	During previous seven (7) years, no conviction for vehicular homicide or vehicular assault
	•	Proof of financial responsibility (SR 22)
Financial Obligations	•	$100 mandatory fee to DOL
	•	Costs to install, remove, and lease the ignition interlock device, and $20 fee per month, unless waived
Duration	Extends through the remaining portion of any concurrent or consecutive suspension or revocation imposed as the result of administrative action and criminal conviction arising from the same incident
Operation with Other Requirements	The time period during which the person is licensed under RCW 46.20.385, shall apply on a day-for-day basis toward satisfying the period of time the ignition interlock device restriction is required under RCW 46.20.720 and 46.61.5055

     Court Ordered Ignition Interlock (II) Driver's License and Device: The court may waive II driver's license and device requirements upon written findings of fact when: (i) the devices are not reasonably available in the local area, (ii) the person does not operate a motor vehicle, (iii) the person is not eligible to receive the driver's license under RCW 46.20.385. (RCW 46.61.5055(5) as amended by Laws of 2008, ch. 282, § 14). If the court waives the requirements, the court shall order the person to submit to alcohol monitoring for one (1), five (5), or ten (10) years, and to pay for the monitoring. RCW 46.61.5055(5) (Laws of 2008, ch. 282, §, 14). II device is not required on employer's vehicle driven during business hours upon proof to DOL of employment affidavit. The court sets the calibration level.

     Court Ordered Discretionary Ignition Interlock (II) Device: The court may order discretionary II device requirements that last up to the five (5) years jurisdictional limit of the court. The court sets the duration and calibration level. Discretionary II device restrictions begin after any applicable period of suspension, revocation, or denial of driving privileges. RCW 46.20.720(1) (as amended Chapter 95, Laws 2004).

     Passenger Under Age 16: The Court shall order the installation and use of an II device for not less than 60 days if an IID is not mandatory under RCW 46.20.720 or 46.61.5055(5) and for an additional 60 days if an IID is otherwise mandatory.

     Deferred Prosecution: For application in DUI Deferred Prosecution, see RCW 46.20.385, RCW 46.20.720(2), RCW 10.05.020 and RCW 10.05.140, which require II driver's license and device in a deferred prosecution of any alcohol-dependency based case.

     DOL Imposed Ignition Interlock (II) Device - RCW 46.20.720: For all offenses occurring June 10, 2004 or later, DOL shall require that, after any applicable period of suspension, revocation, or denial of driving privileges, a person may drive only a motor vehicle equipped with a functioning II device if the person is convicted of "an alcohol-related" violation of DUI or Physical Control. The DOL required II device is not required on employer's vehicle during business hours upon proof to DOL of employment affidavit. DOL may waive requirement if the device is not reasonably available in the local area.

	_____________________ Court of Washington
	For ____________________________________
	Plaintiff,	No:
	vs.	Petition for Deferred Prosecution (DPPF) Charges: _____________________________
	Defendant.	Violation Date: ________________________

     Comes Now the defendant and petitions the court for deferred prosecution pursuant to RCW Chapter 10.05, and states as follows:

     1. I allege the wrongful conduct charged is the result of or caused by [ ] Alcoholism [ ] Drug Addiction

[ ] Mental Problems, for which I need treatment.

     2. Unless I receive treatment for my problem, the probability of future reoccurrence is great.

     3. I agree to pay for the cost of diagnosis and treatment, if financially able to do so, subject to RCW 10.05.130.

     4. I understand that the court will not accept a petition for deferred prosecution from a person who sincerely believes that he or she is innocent of the crime(s) charged or does not suffer from alcoholism, drug addiction, or mental problems.

     5. If this charge is a violation of Title 46 or similar municipal ordinance, I have not previously been placed on a deferred prosecution for a Title 46 or similar municipal ordinance violation.

     6. A case history and assessment have been filed with this petition pursuant to RCW 10.05.020.

     7. I understand and acknowledge I have the following rights: (a) to have a lawyer represent me at all hearings; (b) to have a lawyer appointed at public expense if I cannot afford one; (c) to a speedy, public jury trial; (d) to appeal any conviction; (e) to remain silent and not testify; (f) to question witnesses who testify against me; (g) to call witnesses to testify for me, at no cost; (h) to be presumed innocent unless the charge(s) against me is proven beyond a reasonable doubt; and (i) to present evidence and a defense. By deferring prosecution on these charges, I understand I give up my right to: (a) a speedy trial; (b) a jury; (c) testify; (d) question witnesses; (e) call witnesses; and (f) present evidence or a defense.

     8. I stipulate to the admissibility and sufficiency of the facts in the attached police reports. I acknowledge that the above items will be entered and used to support a finding of guilty if the deferred prosecution is revoked.

     9. If my deferred prosecution is revoked and I am found guilty, I understand that I may be sentenced up to the maximum penalty allowed by law.

     10. I understand that if I proceed to trial and I am found guilty, I may be allowed to seek suspension of some or all fines and incarceration if I seek treatment. I understand that I may seek treatment from a public or private agency at any time, whether or not I have been found guilty or placed on deferred prosecution.

     11. I understand that for some crimes, a deferred prosecution will enhance mandatory penalties for subsequent offenses committed within a seven-year period. I understand that a deferred prosecution will be a prior offense under RCW 46.61.5055 (driving under the influence, physical control of a vehicle under the influence, negligent driving if originally charged as driving under the influence or physical control of a vehicle under the influence, vehicular homicide, or vehicular assault).

     12. I understand that if the court grants this Petition, I may not operate a motor vehicle on the public highways without a valid operator's license and proof of liability insurance pursuant to RCW 46.29.490. I understand that if my wrongful conduct is the result of or caused by alcohol dependency, I shall also be required to apply for an ignition interlock driver's license and to install an ignition interlock device under RCW 46.20.720(2) and RCW 46.20.385. The required periods of use of the interlock shall be not less than the periods provided for in RCW 46.20.720 (23)(a), (b) and (c). I may also be required to pay restitution to victims, pay court costs, and pay probation costs authorized by law. To help ensure continued sobriety and reduce the likelihood of reoffense, the court may order reasonable conditions during the period of the deferred prosecution including, but not limited to, attendance at self-help recovery support groups for alcoholism or drugs, complete abstinence from alcohol and all nonprescribed mind-altering drugs, periodic urinalysis or breath analysis, and maintaining law-abiding behavior. Alcoholism programs shall require a minimum of two self-help recovery groups per week for the duration of the treatment program. The court may terminate the deferred prosecution program if I violate this paragraph.

     13. I understand that if the court grants this Petition, during the period of deferred prosecution 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 my wrongful conduct 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 me to register as a sex offender in Washington state. I understand that I will be required to pay an application fee with my travel or transfer request.

     14. I understand that if I fail or neglect to comply with any part of my treatment plan or with any ignition interlock driver's license or ignition interlock device requirements, then the court will hold a hearing to determine whether I should be removed from the deferred prosecution program shall either order me to comply with the term or condition or be removed from deferred prosecution (RCW 10.05.090). After the hearing, the court will either order that I continue with treatment or be removed from deferred prosecution and enter judgment. If I am convicted of a similar offense during the deferred prosecution, the court will revoke the deferred prosecution and enter judgment.

     15. I understand that the charge(s) against me in this case will be dismissed three years from the end of the two-year treatment program and following proof to the court that I have complied with the conditions imposed by the court following successful completion of the two-year treatment program, but no less than five years from the date the deferred prosecution is granted, if the court grants my petition for deferred prosecution and if I fully comply with all the terms of the court order placing me on deferred prosecution.

     I certify under penalty of perjury under the laws of the state of Washington that I have read the foregoing and agree with all of its provisions and that all statements made are true and correct.

Dated at __________________, Washington this ____ day of ________________________, ______.

Petitioner-Defendant		Defense Attorney/WSBA No.

	_____________________ Court of Washington
	For ____________________________________
	Plaintiff,	No:
	vs.	Petition for Deferred Prosecution of Criminal Mistreatment Charge (DPPF) Charges: _____________________________
	Defendant.	Violation Date: ________________________

     Comes Now the defendant and petitions the court for deferred prosecution of a criminal mistreatment charge pursuant to RCW Chapter 10.05, and states as follows:

     1. I am the natural or adoptive parent of the alleged victim.

     2. The wrongful conduct charged is the result of parenting problems for which I am in need of services.

     3. I am in need of child welfare services under chapter 74.13 RCW to improve my parenting skills in order to better provide my child(ren) with the basic necessities of life.

     4. I want to correct my conduct to reduce the likelihood of harm to my child(ren).

     5. I have cooperated with the Department of Social and Health Services to develop a plan to receive appropriate child welfare services.

     6. I agree to pay the cost of the services if I am financially able to do so.

     7. I understand that the court will not accept a petition for deferred prosecution from me if I sincerely believe that I am innocent of the crime(s) or if I sincerely believe that I do not need child welfare services.

     8. I have not previously been placed on a deferred prosecution for a Chapter 9A.42 RCW or similar municipal ordinance violation.

     9. The Department of Social and Health Services' case history and child welfare service plan have been filed with this petition pursuant to RCW 10.05.020.

     10. I understand and acknowledge I have the following rights: (a) to have a lawyer represent me at all hearings; (b) to have a lawyer appointed at public expense if I cannot afford one; (c) to a speedy, public jury trial; (d) to appeal any conviction; (e) to remain silent and not testify; (f) to question witnesses who testify against me; (g) to call witnesses to testify for me, at no cost; (h) to be presumed innocent unless the charge(s) against me is proven beyond a reasonable doubt; and (i) to present evidence and a defense. By deferring prosecution on these charges, I understand I give up my right to: (a) a speedy trial; (b) a jury; (c) testify; (d) question witnesses; (e) call witnesses; and (f) present evidence or a defense.

     11. I stipulate to the admissibility and sufficiency of the facts in the attached police reports. I acknowledge that the above items will be entered and used to support a finding of guilty if the deferred prosecution is revoked.

     12. If my deferred prosecution is revoked and I am found guilty, I understand that I may be sentenced up to the maximum penalty allowed by law.

     13. I understand that if I proceed to trial and I am found guilty, I may be allowed to seek suspension of some or all fines and incarceration if I seek treatment. I understand that I may seek treatment from a public or private agency at any time, whether or not I have been found guilty or placed on deferred prosecution.

     14. I understand that if the court grants this petition, I may not operate a motor vehicle on the public highways without a valid operator's license and proof of liability insurance pursuant to RCW 46.29.490. I understand that if my parenting problems and resulting wrongful conduct are based on alcohol dependency, I shall also be required to apply for an ignition interlock driver's license and to install an ignition interlock device under RCW 46.20.720(2) and RCW 46.20.385. The required periods of use of the interlock shall be not less than the periods provided for in RCW 46.20.720 (23)(a), (b), and (c). I may also be required to pay restitution to victims, pay court costs, and pay probation costs authorized by law. To help ensure continued sobriety and reduce the likelihood of reoffense, the court may order reasonable conditions during the period of the deferred prosecution including, but not limited to, attendance at self-help recovery support groups for alcoholism or drugs, complete abstinence from alcohol and all nonprescribed mind-altering drugs, periodic urinalysis or breath analysis, and maintaining law-abiding behavior. Alcoholism programs shall require a minimum of two self-help recovery groups per week for the duration of the treatment program. The court may terminate the deferred prosecution program if I violate this paragraph.

     15. I understand that if the court grants this Petition, during the period of deferred prosecution 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 my wrongful conduct 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 me to register as a sex offender in Washington state. I understand that I will be required to pay an application fee with my travel or transfer request.

     16. I understand that if I fail or neglect to comply with any part of my service plan, or with any ignition interlock driver's license or ignition interlock device requirements, the court will hold a hearing to determine whether I should be removed from the deferred prosecution program shall either order me to comply with the term or condition or be removed from deferred prosecution (RCW 10.05.090). The termination of my parental rights with regard to the alleged victim due to abuse or neglect that occurred during the pendency of the deferred prosecution shall be per se evidence that I did not successfully complete the service plan. After the hearing, the court will either order that I continue with treatment or be removed from deferred prosecution and enter judgment. If I am convicted of a similar offense during the deferred prosecution, the court will revoke the deferred prosecution and enter judgment.

     17. I understand that if the court grants my petition for deferred prosecution, the charge(s) against me in this case will be dismissed when the court receives proof that I have successfully completed the child welfare service plan, or the service plan has been terminated because the alleged victim has reached his or her majority and there are no other minor children in the home.

     I certify under penalty of perjury under the laws of the state of Washington that I have read the foregoing and agree with all of its provisions and that all statements made are true and correct.

Dated at __________________, Washington this ____ day of _________________________, ______.

Petitioner-Defendant		Defense Attorney/WSBA No.