Are you inquiring for yourself or someone else?

Myself Someone Else

Name:*

Address:*

City:*

State:*

Zip Code:*

Main Contact Numbers

Cell*

Home:

Work:

Email Address:*

What Town or Village Court are you charged in?

What County is it in?

Were you (or the person you are contacting us on behalf of) arrested?

Yes No Don't Know

If arrested, indicate the Date of Arrest:

Have you (or the person you are contacting us on behalf of) arrained? (Been brought in front of a judge)

Yes No Don't Know

If so, what is the judge's name?

How long in Jail?

Was bond posted?

Yes No Don't Know

If bond was posted, list $ AMOUNT:

If not arrested, indicate the date ticket was issued:

Are you (or the person you are contacting us on behalf of) employed?

Yes No Don't Know

If employed, list the Occupations(s):

List the Salary:

Current Charges

1192-1 Driving While Ability Impaired by Alcohol

Yes No

1192-2 Driving with .08 of one% or mor alcohol

Yes No

1192-2a Aggravated Driving While Intoxicated .18 of one% or more alcohol

Yes No

1192-3 Driving While Intoxicated

Yes No

1192-4 Driving While Ability impaired - Drugs

Yes No

1192-4a Driving While Ability Impaired - drugs and alcohol

Yes No

List other Vehicle and Traffic charges writtten at the time of DWI tickets:

Have you ever had an alcohol or drug related driving conviction?

Yes No

If so, how long ago?

Less than 5 years 5 to 10 years 10 or more

If you have had more than one prior DWI coviction explain: Where, When, and What was the charge(s)

Did you take a chemical test?

Yes No Don't Know

If yes, which one?

Breath Blood Urine

Do you know the result?

Yes No Don't Know

The result was a

Less than .04.04 to .06.06 to .07.08.09 to .11.12 to .15.15 to .17.18 to .20.21 to .25.25 to .30greater than .31

Was there an accident?

Yes No

If there was an accident was anyone injured?

Yes No Don't Know

Any other prior criminal history? (Please list all history, including traffic tickets)

Are you (or the person you are contacting us on behalf of) currently on probation or parole?

Probation Parole No Don't Know

What for?

Are you (or the person you are contacting us on behalf of) a US citizen?

Yes No Don't Know

Do you ( or the person you are contacting us on behalf of) have a court date?

Yes No Don't Know

If a court date has been set, indicate the following:

Date:

Time:

What court?

What would you like the realistic outcome to be?