• Name: *

• Date of Birth:

• Phone number:

• Alternate phone number:

• Email address:

• Court date written
   on the Ticket: *
   mm/dd/yy:

• Your next court date:
  mm/dd/yy: *

• Date you were stopped:
  mm/dd/yy: *

• In what City and State or Province is your case?

• In what Wisconsin
  county is your case? *

County Adams Ashland Barron Bayfield Brown Buffalo Burnett Calumet Chippewa Clark Columbia Crawford Dane Dodge Door Douglas Dunn Eau Claire Florence Fond du Lac Forest Grant Green Green Lake Iowa Iron Jackson Jefferson Juneau Kenosha Kewaunee La Crosse Lafayette Langlade Lincoln Manitowoc Marathon Marinette Marquette Menominee Milwaukee Monroe Oconto Oneida Outagamie Ozaukee Pepin Pierce Polk Portage Racine Richland Rock St. Croix Sauk Shawano Sheboygan Taylor Trempealeau Vernon Vilas Walworth Washburn Washington Waukesha Waupaca Waushara Winnebago Wood   

• Describe any reason given by the officer for stopping you:

• Describe what really happened:

• Was there an accident?

• If so, was anyone hurt?

• Which 'field sobriety tests did you perform?

walk & turn

walk heel to toe

stand on one leg

finger-to-nose

horizontal gaze nystagmus - watching pen or light moved laterally

vertical nystagmus - watching pen or light moved up and down

alphabet - full

alphabet - partial

finger dexterity - touching thumb to finger tips

counting

• Did you submit to a breath
  or blood test?

breath test at the scene

breath test at police station

blood test at hospital

blood test at police station

I refused a breath test at the scene

I refused a breath test at the police station

I refused a blood test

I was forced to submit to a blood test

• Test results were (if not yet known,  please so indicate): *

• Did you ask for any type of test yourself?

• If so, what type of test?

• Have you been convicted of drunk driving or refusal in the past?  if so, how many times? 

yes     no  

number of prior convictions once in past ten years twice lifetime three times lifetime four times lifetime five or more times lifetime once, over 10 years ago

• In your past cases, did you have an attorney? 

yes     no    
does not apply

• Do you have a Wisconsin driver's license?

• If you do not have a Wisconsin license, what state is your license from?

• Do you have a CDL?

• Do you want to fight the case?

• Are there any other facts that you believe are important?  Please keep in mind that this should NOT include any confidential information, which should be only be discussed personally with your lawyer.