IC 9-30-6-16 : Bureau certificate; form and contents

Sec. 16. The bureau certificate must contain the following information and may be substantially in the following form:

BUREAU OF MOTOR VEHICLES
CERTIFICATE
Date of Arrest		Time	Driver's License No.	License State
		a.m.
	/ /	p.m.
Name: (first)		(M.I.)	(last)	Date of Birth
				/ /

CURRENT Address (street, city, state, zip)

Court Code

Cause Number

Sex

Weight

Height

Eyes

Hair

The above motorist	BUREAU USE ONLY
	REFUSED alcohol test
	FAILED alcohol test 0.%
	Court Determination

It has been determined there was probable cause the defendant violated IC 9-30-5 this ___________ day of ________________, 20__ and that charges are pending herein.

_____________________ Court	______________________ County
	____________________________
	Judge's Signature

[Pre-1991 Recodification Citation: 9-11-4-16.]

As added by P.L.2-1991, SEC.18. Amended by P.L.2-2005, SEC.40.