I would like to discuss my case with you. I enclose the following information:
| Arrest Information |
| Make and model of the car you were driving? |
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| What was the date and time of your stop? |
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| Town of Stop: |
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The officer’s reason(s) for stopping you?
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Where were you stopped? The exact location.
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| Were you driving? |
| Yes No |
| Were you given the Standard Field Sobriety Tests? |
| Yes No |
| Do you have any medical or physical problems? |
| Yes No |
| Do you wear glasses or contacts? |
| Yes No |
| If yes, were you wearing them when performing the Standard Field Sobriety Tests? |
| Yes No |
| Were you arrested? |
| Yes No |
| Did the police officer observe you driving? |
| Yes No |
| Were you involved in an accident? |
| Yes No |
| Did you take either a breath, blood or urine test? |
| Breath Blood Urine None |
| If you took a breath test, state the following: |
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| Were more than two (2) tests given to you? |
| Yes No |
| Were drugs involved, i.e. marijuana, heroin, cocaine, etc.? |
| Yes No |
| Were you charged with driving under the influence of alcohol and or drugs? |
| Alcohol Drugs Alcohol and Drugs |
| Were you charged with any other motor vehicles or criminal charges? |
| Yes No |
| State the name of the police department the arresting officer was from: |
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| State the name and badge number of the arresting officer: |
| Name: Badge: |
| Was it the arresting officer who gave you the breath, blood or urine test? |
| Yes No |
| Have you ever had the Alcohol Education Program in Connecticut or any other State within the past ten (10) years? |
| Yes No |
| If yes, where? |
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| Have you ever been convicted of driving under the influence of alcohol and or drugs in Connecticut or any other State? |
| Yes No |
| If yes, list the name of the State, the date of each charge: |
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You may state anything else you want to discuss with me in this area:
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