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. L i c e n s e
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.
_____________________ Cour_t_____________________ County
____________________________
Judge's Signature
As added by P.L.2-1991, SEC.18. Amended by P.L.2-2005, SEC.40.
Last modified: May 27, 2006