Please
specify how you found us, if not listed above.
Date
of Arrest
Time
of Arrest
Day
of the Week
City
Where Arrested
County
Where Arrested
Court
Date (leave blank if unsure)
Time
of Court
Name
of Court
Driver's
License #
State
Where Licensed
Date
of Birth
Are
you currently on probation or parole?
Yes
No
If
"yes", where?
If
"yes", for what offense(s)?
Other
Tickets or Charges received with this DUI (check all that
apply):
Failure to
Maintain Lane
Speeding
Illegal U-Turn
Running Red Light or Stop Sign
Defective Equipment
No Proof of Insurance
Failure to Yield
Other (Please specify below...)
Please
specify other charges not listed above
Why
were you stopped and arrested, according to the officer?
Was
there an accident?
Yes No
Not Sure
Was
anyone injured? (check all that apply):
No one was
hurt/Not applicable
Myself
Passenger(s) in my vehicle
Passenger(s) in another vehicle
Pedestrian
Not Sure
Were
you stopped at a roadblock?
Yes
No
Were
you given field sobriety tests at the location where you
were stopped?
Yes
No
Don't recall
I Refused
Which
field sobriety tests were you given? (Check all that
apply)
Hand held Breath Test
Walking heel to toe
One-Leg Stand
Follow-the-Pen-With-Eyes
Say the Alphabet
Touch Your Nose
Other (Please specify below...)
Please
specify other tests you took, that are not listed above
Did
officer advise you that field tests were 100% optional and
that no penalty would result from not doing them?
Yes
No
Were
you videotaped at any point during your arrest?
Yes No
Not Sure
Did
the officer request and did
you take a breath, blood, and/or urine test?
Note: If you refused
or if the officer wrote you up for refusing, check the NO
box and explain in the message box below.
Yes
No, I Refused
Not Sure
WARNING:
IF YOU WERE CHARGED WITH REFUSING TO TAKE THE STATE TEST,
OR IF YOU TOOK THE TEST AND REGISTERED AN UNLAWFUL BLOOD
ALCOHOL LEVEL,* YOU ONLY HAVE TEN BUSINESS DAYS
FROM THE DATE OF YOUR ARREST TO
REQUEST AN ADMINISTRATIVE LICENSE SUSPENSION
HEARING. FAILURE TO DO SO COULD RESULT IN AN
ADMINISTRATIVE SUSPENSION OF YOUR DRIVER'S LICENSE FOR UP
TO FIVE YEARS, AND THAT'S BEFORE YOU EVEN GO TO COURT!
SUBMIT THIS FORM NOW TO HAVE AN ATTORNEY ASSESS YOUR
CASE.
*.08
or above if
age 21 or older
.04 or above
if operating a commercial vehicle
.02 or
above if under age 21
If
you took a breath test you should have been given a print-out of
the two test samples. List your breath test results here:
Sample #1
Sample #2
Blood
test results (if known)
Check here if test
results are pending
Name
of testing officer
Name
of arresting officer
Name
of police dept.
Did
you get your own test of your blood, breath or urine?
Yes
No
If
"yes", what was the result?
Check here if test
results are pending
Additional
Comments:
If a
confirmation notice does not appear on your screen after
submitting,
call us toll-free at
1-877-638-4489
for assistance.
