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New York Codes Rules Regulations (Last Updated: March 27,2024) |
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TITLE 22. Judiciary |
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Subtitle D. Forms |
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Chapter VI. Forms for Use in Courts Exercising Criminal Jurisdiction |
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6 V.T.L. chemical tests—affidavit |
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Sec. 1194(3) V.T.L. Form 6 (V.T.L. Chemical Tests - Affidavit) 3/90 __ Court of __ County of __ ___________ x In the Matter of the Application of Indictment/Docket _______ , No. __ (name of applicant) AFFIDAVIT for an order to compel _______ (name of arrestee) to submit to a chemical test, pursuant to V.T.L. § 1194(3) ___________ x STATE OF NEW YORK ) ) ss.: COUNTY OF __ ) _________, being duly sworn, deposes and says that: [name of applicant] 1. I am a [police officer employed by the ] [district [name of police department] attorney as defined in CPL § 1.20(32)]. At [time] [a.m.] [p.m.] on [date], 19 , I placed under lawful arrest for violating subdivision(s) __ of section 1192 of the [name of arrestee] Vehicle and Traffic Law. I make this affidavit in support of an application for an order to compel the arrestee to submit to a chemical test, pursuant to section 1194(3) of the Vehicle and Traffic Law. 2. I have reasonable cause to believe the arrestee was the operator of a motor vehicle, to wit, a registered in the State of __, bearing license plate, [year and make of vehicle] number __ , because In the course of such operation a person other than the operator [was killed] [suffered serious physical injury as defined in section 10.00 of the Penal Law, in that said person (describe nature and extent of injuries) ]. 3. A breath test administered by a police officer in accordance with section 1194(1)(b) of the Vehicle and Traffic Law indicates that alcohol has been consumed by the arrestee. – OR – Based on the totality of the following circumstances, there is reasonable cause to believe that the arrestee was operating a motor vehicle in violation of section 1192 of the Vehicle and Traffic Law (describe specific circumstances indicating violation) 4. After being placed under lawful arrest, the arrestee refused to submit to a chemical test in accordance with the provisions of section 1194 of the Vehicle and Traffic Law, by (describe circumstances of refusal) – OR – After being placed under lawful arrest, the arrestee is unable to give consent to a chemical test in accordance with section 1194 of the Vehicle and Traffic Law because (describe incapacity) WHEREFORE, it is respectfully requested that the Court issue an order requiring the arrestee to submit to a chemical test to determine the alcoholic and/or drug content of his/her blood and directing a person authorized by section 1194(4)(a)(1) of the Vehicle and Traffic Law to withdraw a blood sample from the arrestee for the purpose of determining the alcoholic and/or drug content thereof. Deponent Sworn to before me this day of __ 19 Notary Public |