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