DUI Intake Form Submission

Name

Current Address

Email Address

Phone Number

Emergency Contact Person

Emergency Contact Phone Number

Were you arrested in your current pending legal matter? Were you arrested in your current pending legal matter? Yes No Not sure

Were you driving or in actual physical control of a motor vehicle? Were you driving or in actual physical control of a motor vehicle? Yes No Not sure

Was any vehicle involved registered in your name? Was any vehicle involved registered in your name? Yes No Not sure

Was the vehicle involved insured on the date of the incident? Was the vehicle involved insured on the date of the incident? Yes No Not sure

Did you have any passengers in the vehicle with you? Did you have any passengers in the vehicle with you? Yes No Not sure

Was your Driver's License valid on the date of the incident? Was your Driver's License valid on the date of the incident? Yes No Not sure

Was there an accident involved in this incident? Was there an accident involved in this incident? Yes No Not sure

Was there property damage involved in this incident? Was there property damage involved in this incident? Yes No Not sure

Were any airbags deployed in any vehicle in this incident? Were any airbags deployed in any vehicle in this incident? Yes No Not sure

Were there any injuries to any parties, in eluding yourself, in this incident? Were there any injuries to any parties, in eluding yourself, in this incident? Yes No Not sure

Was anyone, including yourself, hospitalized in this incident? Was anyone, including yourself, hospitalized in this incident? Yes No Not sure

Did you provide any blood or urine samples in this incident? Did you provide any blood or urine samples in this incident? Yes No Not sure

Were any legal or illegal drugs found at the scene in this incident? Were any legal or illegal drugs found at the scene in this incident? Yes No Not sure

Was any open liquor found at the scene in this incident? Was any open liquor found at the scene in this incident? Yes No Not sure

Were any weapons found at the scene in this incident? Were any weapons found at the scene in this incident? Yes No Not sure

Were you physically cooperative with police in this incident? Were you physically cooperative with police in this incident? Yes No Not sure

Was there any form of physical altercation with police in this incident? Was there any form of physical altercation with police in this incident? Yes No Not sure

Did you perform any Standard Field Sobriety Tests (walk and turn, one leg stand, etc.) in this incident? Did you perform any Standard Field Sobriety Tests (walk and turn, one leg stand, etc.) in this incident? Yes No Not sure

Did you perform a Breathalyzer Test in this incident? Did you perform a Breathalyzer Test in this incident? Yes No Not sure

Did the police provide you with the results of any Breathalyzer Tests in this incident? Did the police provide you with the results of any Breathalyzer Tests in this incident? Yes No Not sure

Have you ever been previously arrested for DUI in any state? Have you ever been previously arrested for DUI in any state? Yes No Not sure

You you have any misdemeanor convictions on your criminal record? You you have any misdemeanor convictions on your criminal record? Yes No Not sure

You you have any felony convictions on your criminal record? You you have any felony convictions on your criminal record? Yes No Not sure

Do you have, or have you ever had, a driver's license in any state other than Illinois? Do you have, or have you ever had, a driver's license in any state other than Illinois? Yes No Not sure

Agreement on Attorneys Fees Agreement on Attorneys Fees Upon submitting this form, and in exchange for reduced or waived legal fees, I agree to make weekly payments in good faith towards Attorneys Fees, to the best of my ability, until my balance is paid in full.