N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. VI, form 6
Sec. 1194(3) V.T.L. Form 6
(V.T.L. Chemical
Tests -
Affidavit)
3/90
________ Court of ________
County of ________
________ x
In the Matter of the Application of
Indictment/Docket
________, No. ________
(name of applicant)
AFFIDAVIT
for an order to compel
________
(name of arrestee)
to submit to a chemical test, pursuant to V.T.L. § 1194(3)[FN1]
________ x
STATE OF NEW YORK)
) ss.:
COUNTY OF ________)
________, being duly sworn, deposes and says that:
[name of applicant]
1. I am a [police officer employed by the ____________] [district
[name of police department]
attorney as defined in CPL §1.20(32) ]. At
__
[time] [a.m.] [p.m.] on
[date], 19 ________, I placed
____________ under lawful arrest for violating subdivision(s) ________ of section 1192 of the
[name of arrestee]
Vehicle and Traffic Law. I make this affidavit in support of an application for an order to compel the arrestee to submit to a chemical test, pursuant to section 1194 (3) of the Vehicle and Traffic Law.
2. I have reasonable cause to believe the arrestee was the operator of a motor vehicle, to wit, a
____________ registered in the State of ________, bearing license plate,
[year and make of vehicle]
number ________, because ____________
____________
In the course of such operation a person other than the operator [was killed] [suffered serious physical injury as defined in section 10.00 of the Penal Law, in that said person (describe nature and extent of injuries) ____________
____________].
3. A breath test administered by a police officer in accordance with section 1194 (1)(b) of the Vehicle and Traffic Law indicates that alcohol has been consumed by the arrestee.
- OR -
Based on the totality of the following circumstances, there is reasonable cause to believe that the arrestee was operating a motor vehicle in violation of section 1192 of the Vehicle and Traffic Law (describe specific circumstances indicating violation)
____________
____________
____________
____________
4. After being placed under lawful arrest, the arrestee refused to submit to a chemical test in accordance with the provisions of section 1194 of the Vehicle and Traffic Law, by (describe circumstances of refusal)
____________
____________
____________
____________
- OR -
After being placed under lawful arrest, the arrestee is unable to give consent to a chemical test in accordance with section 1194 of the Vehicle and Traffic Law because (describe incapacity)
____________
____________
____________
____________
WHEREFORE, it is respectfully requested that the Court issue an order requiring the arrestee to submit to a chemical test to determine the alcoholic and/or drug content of his/her blood and directing a person authorized by section 1194 (4)(a)(1) of the Vehicle and Traffic Law to withdraw a blood sample from the arrestee for the purpose of determining the alcoholic and/or drug content thereof.
______________
Deponent
Sworn to before me this day of ________ 19________
______________
Notary Public
[FN1] Strike all items not applicable
N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. VI, form 6