Name: Age: Address: City: State: Zip: Home: Phone: Home: Email: License: Num.
Select
Yes
Non Expiration Date: Arrest: Date of Arrest:
Select
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Arresting Officer: Defense
Did you sleep the night before the arrest?
Select
Yes
No
How Long? Describe food intake on date of arrest (breakfast, lunch, dinner,
snacks): Describe your Activities from the time you woke up until arrest: Where were you going to when you where arrested?
Describe actions and conversations while leaving the place you
were before the arrest: Describe your drinking activities the night before the arrest: Who did you last talk to before your arrest and what was said?
Who did you talk to the last 3 hours before your arrest and what was said?
Was anyone with you when you were arrested and what was their condition?
List information on anyone who witnessed the arrest?
Was a video taken of the arrest:
Select
Yes
No What route had you taken before the arrest? (Include details of
where the stop lights and stop signs were located and how many turns
and stops where made: Describe the weather and traffic conditions at the time of the stop:
Did you see the officer before his lights were activated?
Select
Yes
No When did you first notice the lights? What where you thinking about immediately before you saw the lights? Where was the officer?
Select
Meeting
Following
Side of Road What was your speed: What Lane where you in? Immediately after seeing the lights, what was the first thing you did? What did you think you had done wrong to attract the officer's attention? Describe the first thing you did after stopping your car: What was the first thing the officer said to you? What was your response to the officer? If you had trouble getting your license and registration for the officer - please describe: Describe any further conversation before exiting your car: Did the officer ask you to perform any coordination or field sobriety tests? Describe the lighting in the area: (street lights etc.) Describe road or shoulder conditions where tests where given: Did the officer advise you whether you passed or failed each test as you did it? Describe any physical disabilities or conditions that could have affected your performance on the tests: After the tests, where you told you where under arrest?
Select
Yes
No
Where you told what you where arrested for?
Select
Yes
No
What was the last thing you said (or did) before the officer told you that you where under arrest? What did the officer say to you about being placed under arrest? Where you given your Miranda Warnings?
Select
Yes
No
Where they read to you?
Select
Yes
No
When were you given your Miranda Warning? Where you handcuffed?
Select
Yes
No
Did that make you mad?
Select
Yes
No
Did you make any angry statements to the officer? (describe) Where you handcuffed in the presence of other people? (describe if so) Did you suffer any numbness in your hands or arms? (describe if so) What happened to your car? Was your car searched?
Select
Yes
No
Were you present?
Select
Yes
No
Was anything removed from your car? (if so please list) Describe everything that took place enroute to the jail or hospital: (conversations etc.) Did you ask to go to a restroom?
Select
Yes
No
Select
Yes
No
Do you have any health conditions that affect how often you urinate? (if yes, describe) Did you take a breath test at the jail?
Select
Yes
No
Who operated the breath test? Was a blood test offered?
Select
Yes
No
Did you ask for a blood test?
Select
Yes
No
Room temperature in breath machine room?
Select
Normal
Cold
Hot
Were you advised that you did not have to take the test?
Select
Yes
No
Results of the breath test if known: Why did you take the breath test? Where you ever advised that you had the right to consult with an attorney?
Select
Yes
No
Were you involved in an accident on this date? (describe) Your Record Any prior DWI convictions? (if yes please list) Any Prior felony convictions? (if yes, please list) Please Describe your criminal record prior to this arrest: Work Describe your current employment situation: Will a DWI affect your employment? Have you requested an Administrative License Hearing?
Select
Yes
No
Would you like a copy of your response sent to your email?
