Ind. Code § 9-30-6-16
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 |
IC 9-30-6-16
Pre-1991 Recodification Citation: 9-11-4-16.