Llc Attorney

							                                                                       YEARGAN & YARBROUGH, LLC

5883 Glenridge Dr, Suite 130 - Atlanta, GA 30328-0139                                      Attorney At Law

Office: 404-467-1747 | Cell: 678-358-6141 | Fax: 404-949-0139 | Email: jim@duijim.com | www.duijim.com



         ALL INFORMATION YOU PROVIDE TO US WILL BE KEPT STRICTYLY CONFIDENTIAL. NONE OF YOUR INFOR-
         MATION WILL BE SHARED WITH ANYONE OUTSIDE OF OUR FIRM FOR ANY REASON. PLEASE FEEL FREE TO
         SHARE ANY, AND ALL, INFORMATION WITH US. IF YOU CANNOT REMEMBER THE ANSWER TO A QUESTION,
         OR IF YOU PREFER NOT TO ANSWER A CERTAIN QUESTION, PLEASE LEAVE THAT QUESTION BLANK. PLEASE
         REMEMBER THAT THE MORE INFORMATION WE HAVE THE BETTER WE WILL BE ABLE TO ASSIST YOU.

         PERSONAL CONTACT INFORMATION__________________________________________________________________

         FULL LEGAL NAME __________________________________________________________________________________

         NAME YOU PREFER TO BE CALLED____________________________________________________________________

         ADDRESS____________________________________________________________________________________________

         CITY______________________________________________________STATE________ZIP CODE___________________

         HOME PHONE___________________________________ CELL PHONE________________________________________

         NUMBER YOU PREFERRED TO BE CALLED ON__________________________________________________________

         EMAIL ADDRESS_____________________________________________

         DATE OF BIRTH______________________________________________

         SOCIAL SECURITY NUMBER___________________________________________________________________________

         ARE YOU A UNITED STATES CITIZEN?_________________________


         EMPLOYMENT INFORMATION
         WHILE YOUR OCCUPATION MAY NOT SEEM RELEVANT TO YOUR ARREST FOR DUI CERTAIN OCCUPATIONS MAY
         INFLUENCE YOUR PERFORMANCE ON FIELD SOBRIETY EVALUATIONS. SOME OCCUPATIONS MAY ALSO CAUSE
         YOU TO HAVE HIGHER BLOOD ALCOHOL CONCENTRATION (BAC) READINGS THAN NORMAL ON THE BREATH
         TESTING MACHINES AS WELL AS CAUSING YOU TO BLOW FALSE POSITIVES ON THESE MACHINES. WE WILL
         NOT CONTACT, NOR WILL WE PROVIDE ANY INFORMATION, TO YOUR EMPLOYER. ALL INFORMATION WILL
         BE KEPT STRICTLY CONFIDENTIAL.

         EMPLOYER__________________________________________________________________________________________
         EMPLOYER’S ADDRESS_______________________________________________________________________________
         EMPLOYER ‘S PHONE_________________________________________________________________________________
         JOB TITLE___________________________________________________________________________________________
         EMPLOYED FOR HOW LONG?_________________________________________________________________________
         WHAT ARE YOUR WORK DUTIES?______________________________________________________________________

         LICENSE INFORMATION
         STATE YOU’RE LICENSED IN_________________________________LICENSE NUMBER________________________
         RESTRICTIONS ON LICENSE___________________________________________________________________________
         ENDORSEMENTS ON LICENSE_________________________________________________________________________
         WAS YOUR LICENSE VALID AT THE TIME OF ARREST?___________________________________________________
                                                                       YEARGAN & YARBROUGH, LLC

5883 Glenridge Dr, Suite 130 - Atlanta, GA 30328-0139                                       Attorney At Law

Office: 404-467-1747 | Cell: 678-358-6141 | Fax: 404-949-0139 | Email: jim@duijim.com | www.duijim.com



         IF NOT, WHY WAS IT SUSPENDED OR REVOKED?________________________________________________________
         DO YOU POSSESS A COMMERCIAL DRIVER’S LICENSE (CDL)?____________________________________________
         ARREST INFORMATION_______________________________________________________________________________
         DATE OF ARREST_____________________________________________________________________________________
         CITATION NUMBERS__________________________________________________________________________________
         ARRESTING AGENCY_________________________________________________________________________________
         NAME OF ARRESTING OFFICER________________________________________________________________________
         WHAT ARE ALL OF THE VIOLATIONS THE OFFICER CHARGED YOU WITH?________________________________
         LOCATION OF ARREST________________________________________________________________________________
         ARE YOU FAMILIAR WITH THE AREA YOU WERE STOPPED IN?___________________________________________
         COLOR AND TYPE/MAKE OF THE VEHICLE YOU WERE DRIVING__________________________________________
         WAS THE VEHICLE YOU WERE STOPPED IN YOUR VEHICLE?_____________________________________________
         WHY WERE YOU STOPPED INITIALLY?_________________________________________________________________
         DID YOU TELL THE OFFICER THAT YOU HAD BEEN DRINKING?___________________________________________
         IF SO, HOW MUCH DID YOU SAY HAD TO DRINK?_______________________________________________________
         WERE THERE ANY PASSENGERS IN THE VEHICLE?______________________________________________________
         HAD THEY BEEN DRINKING?__________________________________________________________________________
         WERE THERE ANY OPEN CONTAINERS IN THE VEHICLE?________________________________________________
         IF SO, WHERE WERE THEY LOCATED IN THE VEHICLE?__________________________________________________
         WERE THERE ANY DRUGS IN THE VEHICLE?____________________________________________________________
         IF SO, WHERE WERE THE DRUGS LOCATED?____________________________________________________________
         DID YOU PERFORM FIELD SOBRIETY EVALUATIONS?___________________________________________________
         WHICH FIELD EVALUATIONS DID YOU PERFORM?_______________________________________________________

         FOLLOW PEAN WITH EYES _______________________WALK THE LINE _______ STAND ON ONE LEG _________
         ROADSIDE BREATH TEST _________________________
         RECITE THE ALPHABET ______TILT YOUR HEAD BACK AND ESTIMATE 30 SECONDS ______________________
         FINGER _________________________TO NOSE ________________________COUNT OUT LOUD _________________


         TOUCH YOUR FINGERTIPS __________________ESTIMATE THE CURRENT TIME ____________________________

         DO YOU RECALL, IMMEDIATELY AFTER YOUR ARREST, IF THE OFFICER TOOK AN ORANGE CARD OUT OF
         HIS POCKET, READ IT TO YOU, AND ASKED YOU FOR A BREATH, OR BLOOD, TEST?________________________
         IF SO, WAS THIS CARD READ TO YOU AT THE SCENE WHERE YOU WERE STOPPED, IMMEDIATELY AFTER YOU WERE
         ARRESTED, OR WAS IT READ LATER ON, OR AT A LOCATION OTHER THAN WHERE THE OFFICER STOPPED YOU?
         DID THE OFFICER READ YOU YOUR MIRANDA RIGHTS?_________________________________________________
         DID YOU EVER, AT ANY POINT, TELL THE OFFICER THAT YOU WANTED TO SPEAK WITH AN ATTORNEY?______________
         DID YOU TAKE A BREATH TEST AT THE JAIL OR AT A MOBILE TESTING FACILITY, OR DID YOU REFUSE TO
         TAKE A STATE REQUESTED CHEMICAL TEST?___________________________________________________________
         IF YOU TOOK A BREATH TEST WAS IT ADMINISTERED AT THE JAIL, OR AT A MOBILE TESTING UNIT?
         _____________________________________________________________________________________________________
                                                                       YEARGAN & YARBROUGH, LLC

5883 Glenridge Dr, Suite 130 - Atlanta, GA 30328-0139                                       Attorney At Law

Office: 404-467-1747 | Cell: 678-358-6141 | Fax: 404-949-0139 | Email: jim@duijim.com | www.duijim.com



         WHAT WERE THE RESULTS OF THE TEST(S)?____________________________________________________________
         WHAT WAS THE NAME OF THE BREATH TESTING OFFICER (IF DIFFERENT FROM THE ARRESTING OFFICER)?
         DID YOU ASK, OR MENTION, THAT YOU WANTED AN INDEPENDENT BLOOD, BREATH, OR URINE TEST?_____

         DID THE OFFICER TRY TO PERSUADE YOU NOT TO TAKE AN INDEPENDENT TEST BY STATING THAT YOU HAD
         TO FIND YOUR OWN TESTING FACILITY, OR PAY FOR THE TEST YOURSELF?______________________________
         DID YOU TAKE AN INDEPENDENT TEST?_______________________________________________________________
         IF SO, WHAT WERE THE RESULTS OF THE INDEPENDENT TEST?__________________________________________
         HOW LONG WERE YOU IN JAIL?_______________________________________________________________________
         DID THE OFFICER KEEP YOUR DRIVER’S LICENSE?___________

         IN ADDITION TO ALL OF THE TICKETS THE OFFICER GAVE YOU, DID HE ALSO GIVE YOU A REGULAR SIZED
         SHEET OF PAPER WITH A 30 DAY DRIVING PERMIT ON IT?________________
         CRIMINAL HISTORY
         PRIOR CHARGES, OFFENSES, AND ARRESTS CAN HAVE A SERIOUS IMPACT ON YOUR CURRENT CASE.
         PLEASE ANSWER THE FOLLOWING QUESTIONS AS COMPLETELY, AND HONESTLY, AS POSSIBLE.

         IS THIS YOUR FIRST DUI ARREST?_____________________________________________________________________

         IF NOT, WHERE WERE YOUR PRIOR ARRESTS, AND WHAT WAS THE OUTCOME OF THESE CASES?
         _____________________________________________________________________________________________________
         DO YOU HAVE ANY PENDING CRIMINAL CHARGES ANYWHERE ELSE?___________________________________
         IF SO, WHERE ARE THESE CHARGES PENDING, AND WHICH OFFENSES ARE YOU CHARGED WITH?
         _____________________________________________________________________________________________________
         ARE YOU CURRENTLY ON PROBATION, OR PAROLE?__________________
         IF SO, WHERE ARE YOU ON PROBATION, OR PAROLE, AND FOR WHICH OFFENSES?
         _____________________________________________________________________________________________________
         HOW MUCH TIME DO YOU HAVE LEFT ON YOUR PROBATION, OR PAROLE?_______________________________
         DOES YOUR PROBATION, OR PAROLE, OFFICER KNOW ABOUT YOUR CURRENT ARREST?__________________
         COURT DATE_________________________________________________________________________________________
         WHICH COURT ARE YOU SCHEDULED TO APPEAR IN?___________________________________________________
         WHEN IS YOUR COURT DATE?_________________________________________________________________________
         WHAT TIME ARE YOU SCHEDULED TO APPEAR IN COURT?______________________________________________
         WHAT IS THE ADDRESS OF THE COURTHOUSE LISTED ON YOUR TICKET?
         ______________________________________________________________________________________________________

         I AFFIRM THAT ALL STATEMENTS CONTAINED ON THESE THREE (3) PAGES ARE TRUE AND ACCURATE. I AM
         AWARE THAT PROVIDING INCORRECT INFORMATION CAN HINDER THE ABILITY OF YEARGAN &
         YARBROUGH, LLC TO PROVIDE THE BEST DEFENSE POSSIBLE, WHICH COULD DAMAGE MY CASE RESULT-
         ING IN HARSHER LEGAL PENALITIES, OR THEIR WITHDRAWING FROM MY REPRESENTATION.

         ____________________________________________________________________________________________________
         Signature                                                         Date