Form Dl-26 - Chemical Testing Warnings And Report
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2DL-26 (12-03)
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
DATE OF BIRTH
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
MONTH
DAY
YEAR
SECTION 1547 - CHEMICAL TESTING WARNINGS
1. Please be advised that you are under arrest for driving under the influence of alcohol or 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. It is my duty as a police officer to inform you that if you refuse to submit to the chemical test, your operating privilege will be suspended for at
least one year. In addition, if you refuse to submit to the chemical test, and you are convicted of, plead to, or adjudicated delinquent with respect
to violating Section 3802(a) of the Vehicle Code, because of your refusal, you will be subject to the more severe penalties set forth in Section
3804(c) of the Vehicle Code, which include a minimum of 72 hours in jail and a minimum fine of $1,000.00
4. It is also my duty as a police officer to inform you that you have no right to speak with an attorney or anyone else before deciding whether to
submit to testing and any request to speak with an attorney or anyone else after being provided these warnings or remaining silent when
asked to submit to chemical testing will constitute a refusal, resulting in the suspension of your operating privilege and other enhanced criminal
sanctions if you are convicted of violating Section 3802(a) of the Vehicle Code.
I certify that I have READ the above warning to the motorist regarding the suspension of their operating privilege and gave the
motorist an opportunity to submit to chemical testing.
Signature of Officer: ___________________________________________________
Date: __________________________
I have been advised of the above.
Signature of Motorist: ___________________________________________________
Date: __________________________
Motorist refused to sign, after being advised.
Signature of Officer: ___________________________________________________
Date: __________________________
AFFIDAVIT
1. The above motorist 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 motorist had been driving, operating or in actual physical
control of the movement of a motor vehicle while under the influence of alcohol or a controlled substance or both.
or
That the above named motorist was involved in an accident in which the operator or passenger of any vehicle involved or a pedestrian
required treatment at a medical facility or was killed.
2. The above motorist was requested to submit to chemical testing as authorized by Section 1547 of the Vehicle Code.
3. The above motorist was read by a police officer of the chemical test warnings contained in paragraph 3 and 4 above.
4. The above named motorist refused to submit to chemical testing after having been read the above warnings.
OFFICER NOTE: The refusal to sign this form is not a refusal to submit to the chemical test. You must still give the motorist an
opportunity to take the chemical test after reviewing this form. If the individual was operating a commercial motor vehicle while having
any alcohol or a controlled substance in their system, you must also complete the reverse side of this form. I certify that all informa-
tion given in this form is true and correct.
Officer Signature: ___________________________________________________________________________________________________________
Officer Name: ______________________________________________________________________________________________________________
(Type or Print)
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:
__________________________________________________________________________________________________________________________________
Forward to:
Department of Transportation
Note: Any pertinent facts not covered by the affidavit should be submitted on a
Bureau of Driver Licensing
separate sheet and attached hereto. That sheet should include the names of
P.O. Box 60037
additional witnesses necessary to prove the elements to which you have at-
Harrisburg, PA 17106-0037
tested.
THIS FORM MAY BE DUPLICATED
ADDITIONAL SUPPLIES OF THIS FORM MAY BE SECURED BY COMPLETING FORM OS-511A
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