1. *Name
2. *Address 1
3. Address 2
4. *City
5. *State
6. Zip Code
ex. 49008
7. *Phone number
ex. (555) 555-5555
8. Okay to call you at this number?
Yes No
9. Alternate phone number
ex. (555) 555-5555
10. Okay to call you at this number?
Yes No
11. Alternate number is a
Pager Celluar Family Member/Friend Business Other
12. Fax
ex. (555) 555-5555
13. Okay to fax you at this number?
Yes No
14. *Email
(ex. someone@someone.com)
15. Okay to email you at this address?
Yes No
16. How did you find this website?
17. Date of birth
ex. 12/01/1970
18. Driver's license number
19. State where licensed
21. Is this your first DWI on your lifetime - anywhere, anytime?
Yes No
22. If you have had prior DWIs please list them below:
23. Are you currently on probation or parole?
Yes No
24. If "yes," where?
25. If "yes," for what offense(s)?
27. Date of arrest
ex. 12/01/2004
28. Time of arrest
ex. 12:50 PM
29. Day of the week
30. State where arrested
31. City where arrested
32. County where arrested
33. Street or location where stopped
34. County where stopped
35. Court date (leave blank if unsure)
36. Time of court
37. Name of court
38. Name of arresting officer
39. Name of police department
41. Are you mainly interested in fighting your DWI, or do you want to plead nolo or guilty?
Fight the case Plead nolo Plead guilty Not sure
42. Other Tickets/Charges received with this DWI (check all that apply):
Failure to Maintain Lane Speeding Illegal U-Turn Running Red Light or Stop Sign Defective Equipment No Proof of Insurance Reckless Driving Failure to Yield Other
43. Why were you stopped/arrested, according to officer?
44. Was there an accident?
Yes No Not sure
45. 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
46. Were you stopped at a roadblock?
Yes No
47. Were you given field sobriety tests at the location where you were stopped?
Yes No Don't recall Refused
48. Which field sobriety tests were you given? (Check all that apply)
Handheld Breath Test Walk-and-turn 9 steps heel to toe One-Leg Stand Follow-the-Pen-With-Eyes Say the Alphabet Touch Your Nose Other
49. Did officer advise you that field tests were 100% optional and that no penalty would result from not doing them?
Yes No
50. Were you videotaped at any point during your arrest?
Yes No Not sure
51. Did you take a breath test?
Yes No, I refused No, test was not offered to me No, I was given a blood test No, I was given a urine test I was given all three tests Not sure
WARNING! If you refused to take a breath, blood or urine test after being arrested for DWI / UBAL / OUIN / OWI or another drinking related charge in Michigan, your license may be at risk of being suspended if you do not take appropriate action to demand an administrative hearing within 14 business days after your arrest. Contact our office immediately to protect your license.
If you took a breath test you should POSSESS a print-out of the two test samples. List your breath test results here:
54. Sample #1
ex. 0.08
55. Sample #2
ex. 0.08
56. Blood test results (if known)
57. Name of testing officer
58. Was your car towed?
Yes No
59. Who authorized the tow truck?
I did Officer did Not sure
60. Who posted bond?
I did Bonding company Family Member/Friend Other
61. Amount of bond
62. Were there any witnesses with you who could testify for you?
Yes No
63. At any time during your arrest did you ever ask for or inquire about getting your own independent blood, breath or urine test?
Yes No
64. Did you get an independent blood, breath or urine test?
Yes No
65. If "yes", what was the result?
Check here if results are pending
66. Did you ever ask to call an attorney?
Yes No
67. If "yes", when (give details)?
68. Additional comments:
