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DL-26 (3-12)

CHEMICAL TESTING WARNINGS AND REPORT OF REFUSAL TO

SUBMIT TO CHEMICAL TESTING AS AUTHORIZED BY SECTION

1547

OF THE VEHICLE CODE IN VIOLATION SECTION 3802

(relating to driving under the influence of Alcohol or Controlled Substance)

Side 1

NAME

SEX

D A T E O F B I R T H

MONTH

DAY

YEAR

FIRST

MIDDLE

LAST

ADDRESS:

CITY

STATE

ZIP CODE

A P.O. Box number may be used in addition to the actual residence address, but cannot be used as the only address.

DRIVER NUMBER

STATE

CHEM TEST REQUEST DATE

SOCIAL SECURITY NUMBER

CDL Holder

MONTH

DAY

YEAR

o YES

o NO

SECTION 1547 - CHEMICAL TESTING WARNINGS

NOTE TO OFFICER: Please read all of these warnings in their entirety to the operator even if the operator is not listening, is

talking over you or is otherwise disruptive. An officer's duty to read these warnings is excused only in rare instances where the

operator's actions make reading this form impossible. You must still give the operator an opportunity to take the chemical test

after you finish reading these warnings to the operator. The refusal of the operator to sign this form is not a refusal to submit to

the chemical test. If the operator was operating a commercial motor vehicle while having any alcohol or a controlled substance in

his/her system, you must also read the warnings on the reverse side of this form and complete the form.

It is my duty as a police officer to inform you of the following:

1. You are under arrest for driving under the influence of alcohol or a controlled substance in violation of Section 3802 of the Vehicle Code.

2. I am requesting that you submit to a chemical test of ______________________ (blood, breath or urine. Officer chooses the chemical test).

3. If you refuse to submit to the chemical test, your operating privilege will be suspended for at least 12 months. If you previously refused a chemical test or

were previously convicted of driving under the influence, you will be suspended for up to 18 months. In addition, if you refuse to submit to the chemical test,

and you are convicted of violating Section 3802(a)(1) (relating to impaired driving) of the Vehicle Code, then, because of your refusal, you will be subject

to more severe penalties set forth in Section 3804(c) (relating to penalties) of the Vehicle Code. These are the same penalties that would be imposed

if you were convicted of driving with the highest rate of alcohol, which include a minimum of 72 consecutive hours in jail and a minimum fine of

$1,000.00, up to a maximum of five years in jail and a maximum fine of $10,000.

4. You have no right to speak with an attorney or anyone else before deciding whether to submit to testing. If you request to speak with an attorney or anyone

else after being provided these warnings or you remain silent when asked to submit to chemical testing, you will have refused the test.

I certify that I have READ the above warnings to the operator regarding the suspension of his/her operating privilege and gave the operator an

opportunity to submit to chemical testing.

Signature of Officer: _____________________________________________________

Date:__________________________

I have been advised of the above.

Signature of Operator:____________________________________________________

Date:__________________________

Operator refused to sign, after being advised.

Signature of Officer: ______________________________________________________

Date:__________________________

AFFIDAVIT

1. The above operator was placed under arrest for driving under the influence of alcohol or a controlled substance in violation of Section 3802 of the Vehicle

Code, and there were reasonable grounds to believe that the above operator had been driving, operating or in actual physical control of the movement of a

vehicle while in violation of Section 3802.

2. The above operator was requested to submit to chemical testing as authorized by Section 1547 of the Vehicle Code.

3. The above operator was read by a police officer the chemical test warnings contained in paragraphs 1 through 4 above.

4. The above operator refused to submit to chemical testing after having been read the above warnings.

I certify that all the information given in this form is true and correct to the best of my knowledge, information and belief. I understand that false

statements made herein are subject to the penalties of 18 Pa.C.S. §4904 relating to unsworn falsification to authorities:

Officer Signature: _____________________________________________________________________________________________________________

Officer Name: ________________________________________________________________________________________________________________

Badge Number: _____________________Jurisdiction: ________________________________________________________________________________

Mailing Address _______________________________________________________________________________________________________________

__________________________________________________________________ Phone: ( _______) _________________________________________

PLEASE LIST NAME, BADGE NUMBER, AND PHONE NUMBER OF ARRESTING OFFICER IF NOT THE SAME OFFICER WHO WITNESSED

THE REFUSAL: ________________________________________________________________________________________________________

Note: Any pertinent facts not covered by the affidavit should be submitted on a separate sheet and attached hereto. That sheet should include the

names of additional witnesses necessary to prove the elements to which you have attested.

Forward to: Department of Transportation, Bureau of Driver Licensing, P.O. Box 60037, Harrisburg PA 17106-0037

THIS FORM MAY BE DUPLICATED

Dl-26 - Chemical Testing Warnings And Report Of Refusal To Submit To Chemical Testing As Authorized By Section 1547 Of The Vehicle Code In Violation Section - Pennsylvania Department Of Transportation

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