Court of Common Pleas of Schuylkill County

Criminal Court Form No. 22 Revised 03/12/03 COURT OF COMMON PLEAS OF SCHUYLKILL COUNTY CRIMINAL DIVISION

COMMONWEALTH OF PENNSYLVANIA : No. : Charge: v. : : Prosecutor: : Victim: : Date of Offense: $50 CJEA $25 EMS $500 Assessment Fee $75 MCARE ARD PROGRAM AGREEMENT AND WAIVER

AND NOW, this ______day of ______, 20____, the undersigned Defendant in the above case, having been accorded the privilege of consideration for acceptance into the Accelerated Rehabilitative Disposition Program (ARD) which offers an opportunity to earn dismissal of the charges pending against me in this case and thus avoiding a record of conviction of the criminal offense(s) charged, does hereby waive the following protections afforded by any applicable Federal or State Constitutional provision, statute or rule of Court: 1. Right to a speedy trial including my rights pursuant to Pa.R.Crim.P. 600. 2. Right to consolidation of all offenses in the event a summary or other final disposition takes place at the time of acceptance into the ARD program including my rights pursuant to 18 Pa.C.S.A. §110 and double jeopardy rights.

I also accept the conditions of my supervision and I agree to comply with all conditions imposed fully. I further certify that I have not had any prior misdemeanor or felony convictions nor have I been granted a prior ARD except as follows: ______. I also acknowledge my voluntary plea of guilty to the summary offenses listed below in this application, which are to be disposed of in conjunction with the ARD disposition. Prior to my admission into the Accelerated Rehabilitative Disposition Program the program has been explained to me. I understand fully that, if I satisfactorily complete the program, the charge(s) against me will be dismissed and that, if I fail to complete the program satisfactorily, I may be prosecuted and tried on these charges as if I never had been in the program. $ Substance Abuse Education Fund – BAC = $ Schuylkill Medical Center

______Assistant District Attorney Defendant * day loss of license ______* 10 hours Community Service Attorney for Defendant * AHSS Criminal Court Form No. 22 Revised 03/12/03 Summary Offenses for Disposition: