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OFFICER’S REPORT AND NOTICE OF DISQUALIFICATION OF COMMERCIAL DRIVING PRIVILEGES

(SEE REVERSE SIDE FOR HEARING INFORMATION)

DRIVER INFORMATION

Name (Last)

(First)

(M/I)

Driver’s License No.

State

Current Address

Date of Birth

Type of Vehicle

City

State

Zip

License Plate No.

Hazardous Material Involved?

o YES

o NO

INSTRUCTIONS: This form must be used to certify a refusal or test result of .04 or greater when a commercial motor vehicle is involved. The CDL advisory in the DC-70 form

should be provided together with the Implied Consent Notice because it will not be known at the time the notices are given whether the person will refuse a test, produce a sample of

.08 or above, produce a sample from .04 to .079, or produce a sample lower than .04. If the person refuses a test or has a test result of .08 or greater, Form DC-27 must also be

completed. A copy of this completed form must be served upon the licensee, along with a completed DC-27 form, if applicable.

LAW ENFORCEMENT OFFICER’S CERTIFICATION

INSTRUCTIONS: To certify a test refusal or test result of .04 or greater, the officer or officers must complete the appropriate statements and initial each of the statements intended to be

certified in the indicated space to the left of each statement and sign in the space provided below. NOTE: TO PROPERLY CERTIFY A STATEMENT, THE STATEMENT MUST BE

INITIALED AND THE OFFICER WHO INITIALS THE STATEMENT MUST ALSO SIGN BELOW.

On the

day of _________________________

, 20

, reasonable grounds existed to believe that the above-named person within the State of Kansas

County, had been driving a commercial motor vehicle, as defined in K.S.A. 8-2,128, and

amendments thereto, while having alcohol or other drugs in such person's system.

The person had been placed under arrest, was in custody or had been involved in a vehicle accident or collision.

The person was presented oral and written notice as required by K.S.A. 8-2,145 and amendments thereto.

The person refused to submit to or complete a test or the test result for alcohol content of blood or breath was .04 or greater.

Please check to indicate which applies:

o the person refused to submit to or complete a test

o the result of the test showed that the person had an alcohol concentration of .04 or greater in such person's blood or breath. (Attach copy of test report.)

_______

Reason(s) for the initial contact and/or stop: o committed traffic violation(s) (explain below)

o officer arrived at scene of accident

o vehicle already stopped

o other (explain) ___________________________________________________

Reasonable grounds for my belief that the person was driving a commercial motor vehicle:

o saw person operate

o person identified self as driver

o saw person in physical control of a commercial motor vehicle

o other (explain)

Reasonable grounds for my belief that the person had alcohol or other drugs in his/her system.

o odor of alcoholic beverages

o alcoholic beverage containers found in vehicle

o failed sobriety tests

o slurred speech

o bloodshot eyes

o difficulty in communicating

o poor balance or coordination

o person stated alcohol/drugs consumed

o failed preliminary screening test

o other (explain)

A copy of this document which contains a Notice of Disqualification of Commercial Driving Privileges is being served by me on the above-named person

on ____________________________, 20 _____ by (check one)

Personal Service

Mailing by first-class mail to the above address.

NOTE: PERSONAL SERVICE IS REQUIRED IF THE DETERMINATION OF REFUSAL OR FAILURE IS MADE WHILE THE PERSON IS STILL IN CUSTODY.

I hereby certify to the Department of Revenue, Division of Vehicles that each of the statements I have initialed above are true and accurate, under penalty of

K.S.A. 8-2,145(d), and amendments thereto.

Title and name (printed): _________________________________________

Agency name:

_________________________________________

Agency name:

_________________________________________

Agency address:

_________________________________________

Agency address:

_________________________________________

City/state/zip:

_________________________________________

City/state/zip:

_________________________________________

Signature of Law Enforcement Officer

Completion date of certification: ______________________________________________

TEMPORARY COMMERCIAL DRIVER’S LICENSE

THIS NOTICE IS:

NOT VALID as a temporary license because your license: o has expired

o has been revoked

o has been suspended

o has been cancelled

o you have no

driver’s license. If the reason for invalidity is removed, you may apply for temporary driving privileges within 20 days from the date of service of this notice.

VALID as a temporary license for twenty (20) days from the date of service of this document, subject to any out of service order issued by a law enforcement

officer. You must carry this notice with you when driving. This temporary license allows the operation of the same classes of vehicles and is subject to the same

restrictions as the driver’s license surrendered.

Any temporary commercial driver’s license will end and your commercial driving privileges will be suspended 20 days after service of this document unless an

administrative hearing has been timely requested and the required $50 hearing fee paid, as set out in the INSTRUCTIONS FOR REQUESTING AN

ADMINISTRATIVE HEARING ON THE REVERSE SIDE OF THIS FORM.

CDL-5 (Rev. 07/13)