Full name* In the field above you can enter either your name or a nickname you prefer to go by. Nature of the charges*Select all that apply: OVI / DUI Physical Control while Impaired Vehicular assault Vehicular homicide License plate issues No head lights Speed Left of center Marked Lanes Impeding the flow Assured clear distance Failure to yield Driving under suspension Hit skip Other traffic charges Other criminal charges (such as possession of drugs) Date of Arrest / Citation / Incident* MM slash DD slash YYYY Did you take a breath, blood or urine test?*--- Select ---breath testblood testurine testnoneWhat was the result, if you know?* For the next two questions do not include current charge.Number of prior OVIs / DUIs in the last 10 years?* none 1 2 3 more than 3 Number of prior OVIs / DUIs lifetime:* none 1 2 3 4 5 6 7 more than 7 Prior Court Date - if any MM slash DD slash YYYY Step 2: Contact and Client InformationAdditional contact number:Addtional email address? Best phone number, during the evening, if different:What type of number is this?*-- select --Work numberHome numberCell numberBest times to call: Is there any other person authorized to contact? If so, enter their best phone number:What type of number is this?*-- select --Work numberHome numberCell numberWhat's the name of your employer? What is your job, occupation or position? Enter your home address: Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Age: Date of birth: Social Security #: Drivers license number: Drivers license state. If you do not have an Ohio Drivers license what is the issuing state? Is the license valid? Yes No If your ODL isn't valid, what's the reason?Do you have car insurance? Yes No If so, what's your insurance company's name? Showed proof? Yes No Step 3: Professional Licenses InformationIf you hold a CDL license or a Professional License – or hope to obtain one- in is urgent that we know about it. Please check the appropriate boxes belowPlease check the appropriate boxes below: CDL Law License Medical License Pilot's License Nurse License Stockbroker Car Dealer/sales Dentist Teacher Financial Advisor Chiropractor Realtor/Broker School Bus CDL Mortgage Broker Banker Firefighter Peace Officer Concealed weapon EMS / EMT Liquor License Are you currently a student? Yes No Do you get / hope to get loans or grants or financial aid? Yes No Any other licenses or certificates?Please describe any other license or certificate you might have that may be affected by a DUI convictionDo you ever travel to Canada or other countries? Yes No Are you a US Citizen? Yes No If no, describe your status:Step 4: Details of the StopDate of the arrest? MM slash DD slash YYYY Time of the arrest? Location (city / closest city) Street / Route Number Nearest Cross Street / Exit List the Charges written on the Traffic Ticket and/or CompliantClick the (+) to create a new line in this list.Name of ChargeStatute / Code Number Arresting Agency: Arresting Officer's Name Reason For Stop or contactLook on the BMV 2255 FormThis is the Yellow-Gold Form – In B, what does the officer list after "my reasonable grounds for OVI arrest before test were?" Note: the officer's handwriting and abbreviations are often hard to understand, below write what you think it says:Step 5: Field Sobriety Test DetailsField Sobriety Tests Requested? Yes No Any done / attempted? Yes No Location - check all that apply At the Scene At the Police Station / Patrol Post HGN – Did you take an eye test? Yes No During this test were you standing or sitting? Standing Sitting Did you complete the eye test? Yes No Were there any problems? If so, write them here:Was a walk & turn test requested? Yes No If requested, select which applies: Completed Refused Stopped How did you do? Pretty Good Average Not Good Was a one leg stand test requested? Yes No If requested, select which applies: Completed Refused Stopped How did you do? Pretty Good Average Not Good List any other sobriety test given:Examples include: alphabet, partial alphabet, finger to nose etc. To create another line on the list, click the (+).Other Sobriety TestHow did you do? If you were read your rights, where? Signed Rights Form? Yes No Step 6: Questions and AdmissionsWhat was your response to "have you been drinking?" or other potentially incriminating answers / statements.Did you make any admissions while in car? If so, write them here:Did you make any LATER admissions? If so, WHAT did you say and WHERE, write them here:Did you do jail time? Yes No Enter the dates of your jail time: Was your vehicle impounded? Yes No Enter the date it was released: Step 7: Chemical Test DetailsRoadside Breath Test requested? Yes No Did you take the test? Yes No If so, what were the results?Which test was requested at the Police Station?Check all the tests that were requested. Blood test Breath test Urine test Did you ask to talk to an attorney before deciding whether to take the test? Yes No Were you offered a chance to call an attorney before the test? Yes No Did you TRY to contact an attorney before the test? Yes No If so, who? Did you talk to an attorney before the test? Yes No If so, who? Did you talk to ANYONE before the test? Yes No If so, who? If you submitted to ANY tests, enter them below:If you refused to ANY tests, enter them below:If you refused, did you give any reason(s)? Yes No What reasons did you give?Step 8: Test ResultsResults of the tests you took.Were you given a printout of breath results? Yes No Did they request a urine or blood test?Check all that apply. Urine test Blood test Location What was the name of the testing officer? Attempts Did you receive a test w/ printed results? Yes No What was the result of the traffic ticket?Test 1TimeResultIf no result, the reason:Test 2TimeResultIf no result, the reason:If more tests / attempts please list same info for each below:Step 9: WitnessesPlease list any friends or acquaintances that may be a witness to your case.Enter their name(s) and relationship to you below. Click the (+) to add more people.NameRelationship Type of witness:Enter when your witnesses were with you. With me earlier in the dayWith me in the vehicleWith me after I was releasedStep 10: Prior DUI arrests and/or convictionsYou're almost to the end. Just a few more questions to help us evaluate your case. Number of prior DUI CONVICTIONS, if any:Number of prior DUI ARRESTS, if any:List the following details for any Prior DUI Arrests / Charges and Case resultsClick the (+) to create a new line in the list.Approx Date m/yCt.Convicted-Y/NTrial –Y/NPlea to Prior Refusals to take a Chemical testIf you have ever been asked by an officer to take a chemical test it may affect the length of your license suspension – please provide these details:No. of Prior Refusals:Enter details below year(s) of each refusal:Click the (+) to add another year in the listYearResult in Susp?DUI plea?Actual ALS Hrg. Held? Traffic Tickets in last two years – we want to see if "points" are an issue:Click the (+) to add another year in the listYearChargeResult Traffic Cases requiring a Court Appearance in last 10 years (Not speeding, or minor tickets)Click the (+) to add another year in the listYearChargeResult Past Criminal Cases – list all felonies ever & all misdemeanors in 10 yearsClick the (+) to add another year in the listYearChargeResult Step 11: How did you find us?Please Note: We reward our clients who learned about us via a former client, another lawyer or via a web site (we are listed on several) and provide us with details about the sourceWere you referred by another person, lawyer or law firm? Yes No If you were referred to us by another person, what was their name?We would like to send them a nice thank you note. If you found us online...If you found us via the Internet please tell us what website or search engine you found us on. Avvo SuperLawyers Justia Google Bing Yahoo Facebook Other If you checked other please specify where you found us. NameThis field is for validation purposes and should be left unchanged.
