Free Probation Form 12B - District Court of Connecticut - Connecticut

- ‘ d O4/14/2008 PGQG 1 91 1
Case 3:00-cr—00227-SRU Document 1610 2 FIIG
PROB 49
(3/89)
Ginitzb §tatzs Zlliztmt liuurt
District of Connecticut
Waiver of Hearing to Modify Conditions of Probation/Supervised Release or Extend Term of
Supervision
I have been advised and understand that I am entitled by law to a hearing and assistance of counsel before
any unfavorable change may be made in my Conditions of Probation and Supervised Release or my period of
supervision being extended. By "assistance of counsel," I understand that I have the right to be represented
at the hearing by counsel of my own choosing if I am able to retain counsel. I also understand that I have the
right to request the court to appoint counsel to represent me at such a hearing at no cost to myself ifl am not
able to retain counsel of my own choosing.
I hereby voluntarily waive my statutory right to a hearing and to assistance of counsel. I also agree to
the following modification of my Conditions of Probation and Supervised Release or to the proposed extension
of my term of supervision:
The defendant shall participate in a program approved by the Probation Office for mental health
treatment. The defendant shall pay all, or a portion of the costs associated with treatment, based on the
defendants ability to pay as determined by the probation officer.
Wltnes Signe
U.S. Probation Officer Probationer or Supervised Releasee
3 Qffgt?
Date