TENDER OF PLEA OR ADMISSION 
AND WAIVER OF RIGHTS 

DOCKET NO. 

Trial Court of Massachusetts 
District Court Department 

COURT DIVISION 

NAME OF DEFENDANT 

SECTION I 
  Guilty Plea 

Count No. 

CONDITIONAL TENDER OF PLEA OR ADMISSION 

  Admission to Facts Sufficient for a Finding of Guilty 

  Binding Plea with Charge Concession Under Rule 12(b)(5)(A) 

Defendant's Recommendation(s) 
(include all fees, costs, and conditions 
of probation) 

Prosecutor's Recommendation(s) 
(required when Prosecutor disagrees 
with Defendant's recommendation(s)) 

Judge's Disposition 
Upon rejecting a binding plea or 
non-binding recommendation 

SUSPENDED SENTENCES MAY BE IMPOSED FROM AND AFTER UPON A PROBATION VIOLATION UNLESS OTHERWISE NOTED 

ANY COUNT PLACED ON FILE may be removed from the file at any time and a sentence may be imposed (or be scheduled for trial if no guilty 
finding has been made): (1) at the defendant's request, or (2) if a related conviction or sentence is reversed or vacated, or (3) if it is shown by a 
preponderance of evidence that the defendant committed a new criminal offense, or (4) if it is shown by a preponderance of evidence that: 

The prosecutor may not request that the charge be removed from the file after: 

(date). 

DIST. / MUN. CTS. R. CRIM P. 4(c) REQUIRES COUNSEL TO CONSULT WITH THE PROBATION DEPARTMENT REGARDING PROBATIONARY TERMS

Signature of Defense Counsel or Pro Se Defendant 

Date 

Signature of Prosecutor 

Date 

X 

SECTION II 

X 

JUDGE'S CERTIFICATION 

The Court ACCEPTS the Defendant's tender.

The Court REJECTS the Defendant’s tender. The defendant was informed on the record that if the court were to exceed the defendant’s 
recommendation, the defendant would have the opportunity to withdraw the plea or admission.  After having had an opportunity to consult 
with counsel the Defendant: 

WITHDRAWS the tendered plea or admission.         

ACCEPTS the judge's disposition.

Plea/admission  was  taken  by  videoconference.  All  parties  were  able  to  see  and  hear  one  another.  I  certify  that  I  advised  the 
defendant  of their right to be physically present for this hearing and that the defendant knowingly, intelligently, and voluntarily waived that 
right after being so advised.
An interpreter was used during the colloquy and confirmed on the record that the Notice of Rights in Section III was translated to the 
defendant.

I addressed the defendant directly. I inquired into the defendant’s education and background and am satisfied the defendant fully 
understands all of the rights set forth in Section III, and that the defendant is not under the influence of any substance that would impair 
the defendant's ability to fully understand those rights.  I advised the defendant of the notices contained in Section III pursuant to G.L. c. 
278, § 29D and Mass. R. Crim. P. 12. I find that the defendant has knowingly, intelligently, and voluntarily waived all the rights explained 
on the record and set forth in this form.

Date

Signature of Judge

X

DC-CR 22 (Rev. 2/22)

SECTION III

DEFENDANT’S RIGHTS AND NOTICES (Mass. R. Crim. P. 12 & G.L. c. 278, § 29D)

A criminal defendant has the right to be tried by a jury, or by a judge without a jury, on these charges. The jury would consist of six jurors 
chosen at random from the community, and the defendant may participate in selecting those jurors, who would determine whether the 
defendant was guilty or not guilty. The jury's decision must be unanimous.   By entering a plea of guilty or admission, the defendant waives the 
right to confront, cross-examine, and compel the attendance of witnesses; to present evidence in their defense; to remain silent and refuse to 
testify or provide evidence against themselves, all with the assistance of a defense attorney; and to be presumed innocent until proven guilty 
by the prosecution beyond a reasonable doubt.

A criminal defendant has the right to be aware of (1) the nature and elements of the charge(s) to which they are entering a guilty plea or 
admission; (2) the range of the possible sentence(s); (3) that sentences may be imposed one after the other. 

A plea of guilty or admission to the charges could trigger the provisions of the sex offender registration statute or commitment as a sexually 
dangerous person under G.L. c. 123A, §12.

If the defendant is not a citizen of the United States, the acceptance by the Court of a plea of guilty, plea of nolo contendere, or admission to 
sufficient facts may have consequences of deportation, exclusion from or admission to the United States, or denial of naturalization, pursuant 
to the laws of the United States. 

For a charge to be placed on file, the defendant must freely and voluntarily consent to the filing of that charge on the conditions listed on the 
front of this form.  A defendant has the right at any time to have the court remove it from the file and impose sentence (or schedule it for trial if 
no guilty finding has been made).  The prosecutor may at any time until the date listed on the front of this form request the Court to remove it 
from the file and impose a sentence (or schedule it for trial if no guilty finding has been made) if a related conviction or sentence is reversed or 
vacated, or if the prosecutor proves by a preponderance of the evidence either that the defendant committed a new criminal offense, or that 
any other condition listed on the front of this form has occurred. If the charge is removed from the file and the defendant sentenced, it may 
result in additional punishment in this case.

SECTION IV
SECTION IV

DEFENSE COUNSEL’S CERTIFICATION

I certify that I have explained to the defendant the legal rights and consequences referred to in the above Section III.

Signature of Defense Counsel 

BBO# 

Date 

SECTION V

DEFENDANT'S ACKNOWLEDGEMENT

     [Note:  A defendant’s signature is not necessary to enter a valid guilty plea.  Commonwealth v. Hubbard, 457 Mass. 24, 26 (2010).  A written waiver 
     cannot substitute for an oral colloquy; however, the defendant’s signature on the tender of plea form is additional evidence of the voluntariness of 
     the plea.  Commonwealth v. Furr, 454 Mass. 101, 111 (2009).]

I understand all of my rights and notices described in SECTION III above. I am not now under the influence of any medication, 
drug (including marijuana), alcohol, or other substances that would interfere with my ability to fully understand the 
constitutional and statutory rights that I am waiving when I plead guilty or admit to sufficient facts.

I have decided to plead guilty, or admit to sufficient facts, freely and voluntarily.

Signature of the Defendant 

Date 

X

X

DC-CR 22 (Rev. 2/22)