_______________________________________________________________________________  
 

I.  WAIVER BY PARTY [or PARENT or GUARDIAN if Juvenile] 
I.  当事人 [如系青少年，则为家长或监护人] 弃权声明 

[当事人姓名，如系青少年，则为家长或监护人姓名] 

本人。如果本人希望有律师但无力自行雇请律师，则本法庭将指派公共代理服务委员会以免费或减少收费的方式为本人提供代理。 
Knowing that I have a right to have a lawyer represent me, I NEVERTHELESS ELECT TO PROCEED IN THIS MATTER 
WITHOUT A LAWYER AND WAIVE MY RIGHT TO SUCH A LAWYER. 
本人知晓本人有权由律师代表本人，但本人依然选择在没有律师的情况下参与本案的诉讼，并放弃雇请律师的权利。 

, have been informed by the judge of my 
，已被法官告知本人在本案诉讼的每个阶段均有权由律师代表 

DATED:   _______________________  
日期： 

SIGNATURE OF PARTY, or PARENT or GUARDIAN for juvenile: 
当事人签名或青少年家或监护人签名： 
X  ____________________________________________________________________________   

rinted or Typed Name of Person Signing: 

工整填写或打字填写签名人姓名： 

_______________________________________________________________________________   

   

  P

   

II.  CERTIFICATE AND FINDINGS OF JUDGE 
II.  法官证明和裁定 
In accordance with Supreme Judicial Court Rule 3:10, as amended, and G. L. c. 211D, § 5, I hereby certify that I 
have informed the party or parent or guardian named above of the right to counsel in this case. I further certify 
that, after an oral colloquy with the party or parent or guardian, I find said party or parent or guardian is 
competent to waive counsel and has knowingly and voluntarily elected to proceed without counsel. 
本人兹证明，本人已依照高等司法法院第3:10 号规则（经修订）和《一般法》第211D 章第5 条之规定，向上述当事人、家长或监护人告知其在此案中的
代理诉讼权。本人进而证明，经与该当事人、家长或监护人口头交流，本人裁定该当事人、家长或监护人具备放弃其代理辩护权所需的行为能力，已有意和
自愿选择在没有律师的情况下参与本案的诉讼. 

V.] 
[诉] 

  [

 

I, 
本人系 

 

WAIVER OF COUNSEL 
PURSUANT TO S.J.C. RULE 3:10 
放弃代理辩护权声明 
依据S.J.C. RULE 3:10 

COURT DEPARTMENT 
法院部门 

DIVISION OR COUNTY 
分院或县 

TRIAL COURT OF 
MASSACHUSETTS 
马萨诸塞州审理法院 

[In Matter of:] 
 [事由：] 
_____________________________________________________________________  
 

 

 

 

DOCKET NO(S). 
案卷编号. 

The party or parent or guardian 
当事人、家长或监护人 
 
 

 

Additional written findings, if any: 
其他书面裁定（如有）： 

 has executed a waiver of counsel in my presence. 
在本人在场的情况下，已签署放弃代理辩护权声。 
 has refused to sign a waiver. 

拒绝签署放弃代理辩护权声明。 

 

SIGNATURE OF JUDGE 
法官签名 

DATED: ___________________________  
日期： 

X __________________________________________________________________________   

Printed or Typed Name of Judge: 
工整填写或打字填写法官姓名： 

 ____________________________________________________________________________   

Waiver of Counsel SJC Rule 3:10 (TC 11-02-16 ly) – Chinese (11/22/2016)