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 CERTIFICATE Date of Arrest Time Driver's License No. License State a.m. // 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.% Court Determination 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 ____________________________ Judge's Signature [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.