Defendant's Name:
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Date of Birth:
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Address:
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City:
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State:
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Zip Code:
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Your Name (if different than defendant):
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Relationship to Defendant:
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Daytime Telephone:
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Evening Telephone:
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E-Mail Address (required):
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Date of arrest:
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Court Information:
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Name(s) of officers involved in your case:
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Did you perform the field sobriety tests? (i.e., walk and turn, one leg stand, etc)
YES
NO
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Did you request an attorney at any time during the investigation?
YES
NO
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If you requested an attorney, did the officer(s) honor your request?
YES
NO
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Did you invoke your right to remain silent?
YES
NO
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Did you give a blood sample?
YES
NO
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Did you give a urine sample?
YES
NO
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Did you complete a breath test?
YES
NO
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If you did, what were the test results?
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