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Affidavit And Revocation Report Of Law Enforcement Officer Or Chemical Analyst CVR-1A - North Carolina
| Affidavit And Revocation Report Of Law Enforcement Officer Or Chemical Analyst Form. This is a North Carolina form and can be used in Civil Revocation Statewide . |
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NOTE TO OFFICER: The officer should review and follow the instructions on Side Two of this form. ATTACH TEST RECORD TICKET HERE File No. STATE OF NORTH CAROLINA NOTE: A "commercial motor vehicle" is as defined in G.S. 20-4.01(3d). County In The General Court Of Justice District Court Division IN THE MATTER OF: Name Address AFFIDAVIT AND REVOCATION REPORT OF LAW ENFORCEMENT OFFICER CHEMICAL ANALYST The charged offense is impaired supervision or instruction under G.S. 20-12.1. Accordingly, substitute "supervisor/instructor" wherever "driver" appears below. G.S. 20-16.2, 20-16.5, 20-17.8, 20-19(c3), 20-139.1 State Vehicle Type CMV Haz. Mat. Citation No. City Date Of Birth State Zip Race Sex Drivers License No. The undersigned being first duly sworn says: day of , , at (a.)(p.)m., a law 1. I am a law enforcement officer. On the enforcement officer had reasonable grounds to believe the above named person, hereinafter referred to as driver, operated a vehicle ( commercial motor vehicle) in the above named county upon while committing an implied-consent offense in that (Give Street, Highway, Or Public Vehicular Area) . (List Sufficient Facts To Establish Probable Cause) 2. The driver has a drivers license restriction: alcohol concentration. ignition interlock. conditional restoration (Restr: *9). 3. The driver violated a drivers license restriction by: refusing to be transported for testing. not having an operable ignition interlock on the vehicle being driven. failing to personally activate the ignition interlock on the vehicle being driven. exceeding the driver's alcohol concentration limitation. G.S. 20-138.1; 4. A law enforcement officer charged the driver with the implied-consent offense of: Other Implied-Consent Offense: ; and the driver has one or more pending offenses in the following county(ies) for which the drivers license had been or is revoked under G.S. 20-16.5. , a chemical 5. After the driver was charged, I took the driver before analyst authorized to administer a test of the driver's breath. 6. I am a chemical analyst and possess a current permit issued by the Department of Health and Human Services authorizing me to conduct chemical analyses of the breath utilizing the Intox EC/IR II. 7. I informed the driver orally and also gave notice in writing of the rights specified in G.S. 20-16.2(a). I completed informing the driver of the rights as indicated on the attached DHHS 4081. 8. I began observing the driver for the purpose of complying with the observation period requirements for a breath analysis in accordance with the methods/rules approved by the Department of Health and Human Services at (a.)(p.)m. on the day of , . day of , , at (a.)(p.)m., I requested the driver to submit to a 9. On the chemical analysis of his/her breath or blood or urine. For blood or urine, I directed the taking of a blood or urine sample by a person qualified under G.S. 20-139.1. 10. The driver was unconscious or otherwise incapable of refusal and therefore the notification of rights and request to submit to a chemical analysis were not made. I directed the taking of a blood sample by a person qualified under G.S. 20-139.1. 11. The driver submitted to a chemical analysis of his/her breath. I administered the chemical analysis to the driver in accordance with the methods/rules approved by the Department of Health and Human Services using an Intox EC/IR II, and it printed the results of the driver's chemical analysis on the attached test record, DHHS 4082, which is made part of this Affidavit. The most recent preventive maintenance was performed on this Intox EC/IR II on the day of , , as shown on the preventive maintenance record. I provided the driver with a copy of the attached test record before any trial or proceeding in which the results of the chemical analysis may be used. 12. The chemical analysis of the driver's breath indicated an alcohol concentration of 0.15 or more. 13. A sample of the driver's blood or urine was collected for a chemical analysis as indicated on the attached DHHS 4081. 14. The driver willfully refused to submit to a chemical analysis as indicated on the attached DHHS 4082. DHHS 4081. The willful refusal occurred in an implied-consent offense involving death or critical injury to another person. SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME Date Signature Of Official Authorized To Administer Oaths Signature Of Chemical Analyst/Law Enforcement Officer DHHS Permit No. Print Name Of Chemical Analyst/Law Enforcement Officer Magistrate Notary Deputy CSC Assistant CSC CSC Date My Commission Expires County Where Notarized Agency Name SEAL AOC-CVR-1A/DHHS 3907, Rev. 3/09 © 2009 Administrative Office of the Courts Law Enforcement Officer/Analyst Copy American LegalNet, Inc. www.FormsWorkFlow.com NOTES TO LAW ENFORCEMENT OFFICER/CHEMICAL ANALYST NOTE TO LAW ENFORCEMENT OFFICER WHO IS NOT GOING TO administer breath test or read the implied-consent rights: 1. Complete the identifying information at the top, 2. Check the "Law Enforcement Officer" block under "Affidavit and Revocation Report of" in the title section, 3. Review and check as appropriate for this case paragraphs 1-5 (and if the driver is unconscious or incapable of refusing so that the implied-consent rights need not be read, also review and check as appropriate paragraph 10), and 4. Swear or affirm before notary or magistrate, sign and file copies as indicated. NOTE TO LAW ENFORCEMENT OFFICER WHO CHARGES DRIVER AND IS CHEMICAL ANALYST who administers the breath test or reads the implied-consent rights for a blood test: 1. Complete the identifying information at the top, 2. Check both the "Law Enforcement Officer" and "Chemical Analyst" blocks under "Affidavit and Revocation Report of" in the title section, 3. Review and check as appropriate for this case paragraphs 1-14, and 4. Swear or affirm before notary or magistrate, sign and file copies as indicated. NOTE TO CHEMICAL ANALYST WHO IS NOT THE CHARGING OFFICER: 1. 2. 3. 4. Complete the identifying information at the top, Check the "Chemical Analyst" block under "Affidavit and Revocation Report of" in the title section, Review and check as appropriate for this case paragraphs 6-14, and Swear or affirm before notary or magistrate, sign and file copies as indicated. INSTRUCTIONS 1. This form should be used in District Court to prove alcohol concentration in implied-consent criminal cases. 2. This form should be used before the Magistrate for the pretrial civil revo
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