N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. VI, form 6a
Sec. 49 Nav. L. Form 6-A
(Nav. 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 Nav. L. § 49[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) ] [peace officer acting pursuant to his or her special duties]. At
__
[time] [a.m.][p.m.] on,
__
[date] 19________, I placed
[name of arrestee] under lawful arrest for
violating subdivision(s) ________ of section 49 of the Navigation 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 49 of the Navigation Law.
2. I have reasonable cause to believe the arrestee was the operator of a vessel as defined in section 49 (4)(a)(3) of the Navigation Law, because ____________
____________.
In the course of such operation a person other than the operator [was killed] [suffered serious physical injury or personal 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 49 of the Navigation 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 vessel in violation of subdivision 4 of section 49 of the Navigation 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 49 of the Navigation 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 49 of the Navigation 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 or drug content of his/her blood and directing a person authorized by section 49 (4)(e)(1) of the Navigation Law to withdraw a blood sample from the arrestee for the purpose of determining the alcoholic 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 6a