____________ Court
______________County
________________Tennessee	
WAIVER OF RIGHT TO HAVE APPOINTED COUNSEL
 
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Case Number	

_____________________________________ Vs. _________________________________

The undersigned represents to the court that he/she has been informed of the charges against him/her, the nature thereof, the statutory punishment therefore and the right to appointment of counsel upon his representation to the court that he is unable to employ counsel and the reasons therefore, all of which he/she fully understands.  The undersigned now states to the court that he/she does not desire the appointment of counsel, expressly waives the same and desires to appear in all respects in his/her own behalf, which he understands he/she has the right to do.

Date: _________________________				
		Defendant Signature

				
			Judge