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General Incident Information:
How would you like to plead in this incident?  Fight the case. Plead nolo. Plead guilty. I am not sure.

On what date did the incident occur (00/00/00)? / / What was the day of week? Sunday Monday Tuesday Wednesday Thursday Friday Saturday At what time? AM PM In what state did the incident occur? Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming In what city? In what county? What is the court date? / / Time of court? AM PM Name of Court?  Driver's License #: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming List any license restrictions: DOB:  / / Have you ever been charged with a DWI?  If so, list below: No Yes List any prior DWI charges: Include Date, City, State, Court Name, and Result (Guilty, Not Guilty) Other Tickets/Charges received with this DWI? (Check all that apply): Failure to Maintain Lane   Defective Equipment Speeding   No Proof of Insurance Illegal U-Turn   Failure to Yield Running Red Light   Other (Please specify below) Please specify other charges not listed above: Was there an accident? Yes No Not Sure Was anyone injured? (Check all that apply): No one was hurt/Not applicable   Passenger(s) in another vehicle Myself   Pedestrian Passenger(s) in my vehicle   Not Sure Were you stopped at a roadblock? No Yes Were you given field sobriety tests when you were stopped? Yes No Not Sure If yes, what were the results? Passed Failed Not Sure Which field sobriety tests were you given? (Check all that apply): Handheld Breath Test   Follow-the-Pen-With-Eyes Walk-and-turn 9 steps heel to toe   Say the alphabet One-Leg Stand   Touch Your Nose     Other (Please specify below) Please specify other sobriety tests that you took, that are not listed above: Did you perform a breathalyzer test? Yes. No, I refused. No, Test was not offered to me. No, I was given a blood test. Not sure. If yes, what was your blood alcohol level? At what time of day was the breathalyzer test taken? AM PM Did you perform a blood test? Yes. No, I refused. No, Test was not offered to me. No, I was given a breathalyzer test. Not sure. Blood test results? Check here if test results are pending: Did officer advise you that tests were 100% optional and that no penalty would result from not doing them? Yes No Did you ever ask for or inquire about getting your own independent blood, breath or urine test? Yes No Did you get an independent blood, breath or urine test? Yes No If "yes", what was the result? Check here if test results are pending: What was the name of the arresting officer? What type of officer performed the arrest?   City Police County Sheriff State Highway Patrol Not Sure Name of the police department? Was your car towed from the location you were arrested? No Yes Not Sure If yes, who called the tow truck? I did Officer Other / Relative or Friend Not Sure Who posted your bond? I did Bonding Company Other / Relative or Friend Not Sure Amount? Did you ever ask to call an attorney? Yes No Please briefly explain the incident:

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