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*	Last Name:
*	State of Residence:
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	Please Explain Your Legal Need:




	State of Arrest:
	Date of Arrest:
	Time of Day of Arrest:
	Arresting Agency:



	Why were you stopped?


	Does the officer claim you were exceeding the speed limit?
			Yes	No

	Was a DUI Sobriety Checkpoint involved?
			Yes	No

	Was an accident involved?
			Yes	No
			If so, were there injuries?
			Yes	No

	Did you have any passengers?
			Yes	No
			If so, were any of them minors?
			Yes	No

	Did you take any field sobriety tests?
			Yes	No
			If so, how do you think you did on the tests?


	Did you take a "portable" breath test in the field?
			Yes	No
			If so, what was the result?
			How many times did you blow into the device?


	Were you given a breath test later at the police station?
			Yes	No
			If so, what was the result?
			How many times did you blow into the device before there were two readings?


	Are you aware of any physical or medical conditions that could have affected the results?
			Yes	No

	Was a blood sample taken from you?
			Yes	No

	Were you given the choice of blood or breath?
			Yes	No

		Did you refuse to be tested?
			Yes	No
			If so, did an officer give you an "implied consent" warning of the consequences of refusing?
			Yes	No
			Did you sign any document concerning the refusal?
			Yes	No
			After the refusal, was a blood sample taken from you?
			Yes	No

	Did you make any statements to the officer(s) concerning drinking and/or driving or drinking on the night of the arrest?
			Yes	No

	Were you advised of your right to remain sildent and have an attorney present?
			Yes	No




	Did you have any physical or medical conditions that may have affected your performance?
			Yes	No

	What is your age?


	How much do you weigh?


	Did you have a currently valid driver's license in your state?
			Yes	No
			If not, is your license from another state?
			Yes	No

	Was your license confiscated?
			Yes	No

	Was the vehicle impounded?
			Yes	No

	Were you required to post bail?
			Yes	No
			If so, how much?

	Is this your first offense?
			Yes	No

	When have you been cited into court for arraignment?


	What is the name of the court?


	Is a driver's license necessary for your employment?
			Yes	No

	What is your occupation or profession?


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