Los Angeles DUI Guy, Mark Rosenfeld (DUI Attorney) FREE Case Evaluation Submittal Form.

Name*

FirstLast

Email*

Home Phone

Work Phone

Cell Phone

Prefered contact method (Check ALL that apply):

Drivers License Number:

Date of Birth:

Court where you are to appear:

Date you are scheduled to appear:

Is this your first DUI?:*

Yes! My first.
This is my second DUI.
This is my third DUI.

Are you currently on probation or parole?:*

Yes
No

Have you requested your DMV Hearing?:

Yes
No

Date of arrest:

Time of arrest

: HH

MM

City where arrested?:

Which law enforcment agency arrested you? (Ex: California Highway Patrol) :

Did the officer observe you driving a vehicle?:

Yes
No

Did you admit to driving the vehicle?:

Yes
No

Was there an accident?:

Yes
No

Were you stopped at a road block / DUI Check Point?:

Yes
No

Were you under 21 years of age at the time of arrest?:

Yes
No

Was there a child under 14 years of age in the vehicle at the time of arrest?:

Yes
No

If you were on surface streets, were you speeding 20 MPH or more beyond the posted speed limit?:

Yes
No

If you were on surface streets, were you speeding 30 MPH or more beyond the posted speed limit?:

Yes
No

Did you tell the officer you had been drinking?:

Yes
No

What time did you tell the officer that you had your last drink?:

Did you perform any field sobriety tests?:

Yes
No

Did the officer ask you to blow into a handheld breath device at the scene?:

Yes
No

How many times did you blow into the breath device?:

At your arrest, were you advised that you had a choice between a blood or breath test?:

Yes
No

If you took a breath test, was the officer continuously observing you 15 minutes prior to the administration of that test?:

Yes
No

If you took a chemical test (i.e., blood or breath), do you know the result?:

Yes
No

What was the Result?

If you took a breath at the station, how many times did you blow into the machine?

Were there any witnesses to your driving and/or arrest?:

Yes
No

Did the officer advise you of your Miranda Rights?:

Yes
No

Are you aware if you were video-taped at anytime during your arrest?:

Yes
No
I'm not sure

Additional Comments or Questions:

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