2017 Indiana Code
TITLE 9. Motor Vehicles
ARTICLE 30. GENERAL PENALTY PROVISIONS
CHAPTER 6. Implied Consent; Administrative and Evidentiary Matters
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
Date of Arrest Time Driver's License No. License State
/ / 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.%
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
[Pre-1991 Recodification Citation: 9-11-4-16.]
As added by P.L.2-1991, SEC.18. Amended by P.L.2-2005, SEC.40.