, RR Donnelley. All rights reserved CONSECUTIVE NUMBERING BARCODE PTS 1 & 4 ONLY AGENCY NAME AGENCY #

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1 3 1B 1B 2015, RR Donnelley. All rights reserved COSECUTIVE UMBERIG BARCODE PTS 1 & 4 OL FLORIDA DUI UIFORM TRAFFIC CITATIO COUT OF (IF APPLICABLE) I THE COURT DESIGATED BELOW THE UDERSIGED CERTIFIES THAT HE/SHE HAS GROUDS TO AD DOES BELIEVE THAT JUST AD ABLE BELIEVE O (RETAIED B COURT) DA OF WEEK TH DA EAR AME (PRIT) FIRST AGEC AME AGEC # COMPLAIT IF DIFFERET THA OE O LICESE "X" HERE TELEPHOE UMBER OF DA R RACE SEX HGT CLASS CDL LICESE R. LICESE EXP. R. VEHICLE MAKE STLE COLOR VEHICLE LICESE. TRAILER TAG. EAR TAG EXPIRES UPO A PUBLIC OR HIGHWA, OR OTHER LOCATIO, AMEL FT. MILES S E W OF DE DID ULAWFULL COMMIT THE OFFESE OF DRIVIG UDER THE IFLUECE OF ALCOHOLIC BEVERAGES, CHEMICAL OR COTROLLED SUBSTACES; DID DRIVE, OR WAS I ACTUAL PHSICAL COTROL OF A VEHICLE, WHILE UDER THE IFLUECE OF A ALCOHOLIC BEVERAGE/CHEMICAL SUBSTACE/COTROLLED SUBSTACE TO THE EXTET RMAL FACULTIES WERE LICESE UMBER COMMETS PERTAIIG TO OFFESE: (Only one offense each citation) PASSEGER < 18 EARS DAMAGE TO OTHER PROPERT RULES SCREEED 20% IJUR TO ATHER $ COURT COURT AD LOCATIO SERIOUS BODIL IJUR TO ATHER I AGREE AD PROMISE TO COMPL AD ASWER TO THE CHARGES AD ISTRUCTIOS SPECIFIED I THIS CITATIO. WILLFUL REFUSAL TO ACCEPT AD SIG THE CITATIO MA RESULT I ARREST. I UDERSTAD M SIGATURE IS T A ADMISSIO OF GUILT OR WAIVER OF RIGHTS. IF OU EED ABLE FACILIT ACCOMDATIOS TO COMPL WITH THIS CITATIO, COTACT THE CLERK OF THE COURT. X SIGATURE OF VIOLATOR EFFECTIVE IMMEDIATEL, OUR DRIVIG PRIVILEGE IS SUSPEDED/DISQUALIFIED FOR: DRIVIG WITH A ULAWFUL BLOOD OR BREATH ALCOHOL LEVEL. THIS SUSPESIO IS FOR A PERIOD OF SIX THS IF THIS IS THE FIRST VIOLATIO OR OE EAR IF PREVIOUSL SUSPEDED FOR DRIVIG WITH A ULAWFUL BLOOD OR BREATH ALCOHOL LEVEL. IF OU HOLD A CDL OR OU ARE OPERATIG A CMV, OUR COMMERCIAL LICESE/PRIVILEGE WILL ALSO BE DISQUALIFIED FOR OE EAR FOR THE FIRST OFFESE OR PERMAETL DISQUALIFIED FOR A SUBSEQUET OFFESE. REFUSAL TO SUBMIT TO LAWFUL BREATH, BLOOD OR URIE TEST , F. S. THIS SUSPESIO IS FOR A PERIOD OF OE EAR IF THIS IS A FIRST REFUSAL OR 18 THS IF PREVIOUSL SUSPEDED FOR THIS OFFESE. IF OU HOLD A CDL OR OU ARE OPERATIG A CMV, OUR COMMERCIAL LICESE/PRIVILEGE WILL ALSO BE DISQUALIFIED FOR A PERIOD OF OE EAR FOR A FIRST REFUSAL OR PERMAETL DISQUALIFIED FOR A SUBSEQUET REFUSAL. LICESE SURREDERED? ULESS IELIGIBLE, THIS CITATIO SHALL SERVE AS A TEMPORAR LICESE AD WILL EXPIRE AT MIDIGHT O THE 10TH DA FOLLOWIG THE OF SUSPESIO. BUREAU OF ADMIISTRATIVE REVIEWS OFFICE, OU MA REQUEST, WITHI 10 DAS AFTER THE OF SUSPESIO, A REVIEW OF SUSPESIO B THE DEPARTMET OF HIGHWA SAFET AD TOR VEHICLES OR A REVIEW TO DETERMIE ELIGIBILIT FOR A RESTRICTED LICESE IF THIS IS OUR FIRST DUI RELATED OFFESE. SEE REVERSE SIDE. RAK - SIGATURE OF OFFICER BADGE. ID.. TROOP UIT FACE 1

2 2B 2B 2015, RR Donnelley. All rights reserved FLORIDA DUI UIFORM TRAFFIC CITATIO COUT OF (IF APPLICABLE) I THE COURT DESIGATED BELOW THE UDERSIGED CERTIFIES THAT HE/SHE HAS JUST AD ABLE GROUDS TO BELIEVE AD DOES BELIEVE THAT O ABSTRACT OF COURT RECORD FOR LICESIG AUTHORIT REPORT OF DISPOSITIO DA OF WEEK TH DA EAR AME (PRIT) FIRST AGEC AME AGEC # IF DIFFERET THA OE O LICESE "X" HERE TELEPHOE UMBER OF DA R RACE SEX HGT CLASS CDL LICESE R. LICESE EXP. R. VEHICLE MAKE STLE COLOR VEHICLE LICESE. TRAILER TAG. EAR TAG EXPIRES UPO A PUBLIC OR HIGHWA, OR OTHER LOCATIO, AMEL FT. MILES S E W OF DE DID ULAWFULL COMMIT THE OFFESE OF DRIVIG UDER THE IFLUECE OF ALCOHOLIC BEVERAGES, CHEMICAL OR COTROLLED SUBSTACES; DID DRIVE, OR WAS I ACTUAL PHSICAL COTROL OF A VEHICLE, WHILE UDER THE IFLUECE OF A ALCOHOLIC BEVERAGE/CHEMICAL SUBSTACE/COTROLLED SUBSTACE TO THE EXTET RMAL FACULTIES WERE LICESE UMBER COMMETS PERTAIIG TO OFFESE: (Only one offense each citation) PASSEGER < 18 EARS DAMAGE TO OTHER PROPERT IJUR TO ATHER $ COURT COURT AD LOCATIO SERIOUS BODIL IJUR TO ATHER I AGREE AD PROMISE TO COMPL AD ASWER TO THE CHARGES AD ISTRUCTIOS SPECIFIED I THIS CITATIO. WILLFUL REFUSAL TO ACCEPT AD SIG THE CITATIO MA RESULT I ARREST. I UDERSTAD M SIGATURE IS T A ADMISSIO OF GUILT OR WAIVER OF RIGHTS. IF OU EED ABLE FACILIT ACCOMDATIOS TO COMPL WITH THIS CITATIO, COTACT THE CLERK OF THE COURT. X SIGATURE OF VIOLATOR EFFECTIVE IMMEDIATEL, OUR DRIVIG PRIVILEGE IS SUSPEDED/DISQUALIFIED FOR: DRIVIG WITH A ULAWFUL BLOOD OR BREATH ALCOHOL LEVEL. THIS SUSPESIO IS FOR A PERIOD OF SIX THS IF THIS IS THE FIRST VIOLATIO OR OE EAR IF PREVIOUSL SUSPEDED FOR DRIVIG WITH A ULAWFUL BLOOD OR BREATH ALCOHOL LEVEL. IF OU HOLD A CDL OR OU ARE OPERATIG A CMV, OUR COMMERCIAL LICESE/PRIVILEGE WILL ALSO BE DISQUALIFIED FOR OE EAR FOR THE FIRST OFFESE OR PERMAETL DISQUALIFIED FOR A SUBSEQUET OFFESE. REFUSAL TO SUBMIT TO LAWFUL BREATH, BLOOD OR URIE TEST , F. S. THIS SUSPESIO IS FOR A PERIOD OF OE EAR IF THIS IS A FIRST REFUSAL OR 18 THS IF PREVIOUSL SUSPEDED FOR THIS OFFESE. IF OU HOLD A CDL OR OU ARE OPERATIG A CMV, OUR COMMERCIAL LICESE/PRIVILEGE WILL ALSO BE DISQUALIFIED FOR A PERIOD OF OE EAR FOR A FIRST REFUSAL OR PERMAETL DISQUALIFIED FOR A SUBSEQUET REFUSAL. LICESE SURREDERED? ULESS IELIGIBLE, THIS CITATIO SHALL SERVE AS A TEMPORAR LICESE AD WILL EXPIRE AT MIDIGHT O THE 10TH DA FOLLOWIG THE OF SUSPESIO. BUREAU OF ADMIISTRATIVE REVIEWS OFFICE, OU MA REQUEST, WITHI 10 DAS AFTER THE OF SUSPESIO, A REVIEW OF SUSPESIO B THE DEPARTMET OF HIGHWA SAFET AD TOR VEHICLES OR A REVIEW TO DETERMIE ELIGIBILIT FOR A RESTRICTED LICESE IF THIS IS OUR FIRST DUI RELATED OFFESE. SEE REVERSE SIDE. RAK - SIGATURE OF OFFICER BADGE. ID.. TROOP UIT FACE 2

3 3B 3B 2015, RR Donnelley. All rights reserved FLORIDA DUI UIFORM TRAFFIC CITATIO COUT OF (IF APPLICABLE) I THE COURT DESIGATED BELOW THE UDERSIGED CERTIFIES THAT HE/SHE DHSMV RECORD HAS GROUDS TO AD DOES BELIEVE THAT JUST AD ABLE BELIEVE O FORWARD TO DESIGATED DHSMV HEARIG OFFICE DA OF WEEK TH DA EAR AME (PRIT) FIRST AGEC AME AGEC # IF DIFFERET THA OE O LICESE "X" HERE TELEPHOE UMBER OF DA R RACE SEX HGT CLASS CDL LICESE R. LICESE EXP. R. VEHICLE MAKE STLE COLOR VEHICLE LICESE. TRAILER TAG. EAR TAG EXPIRES UPO A PUBLIC OR HIGHWA, OR OTHER LOCATIO, AMEL FT. MILES S E W OF DE DID ULAWFULL COMMIT THE OFFESE OF DRIVIG UDER THE IFLUECE OF ALCOHOLIC BEVERAGES, CHEMICAL OR COTROLLED SUBSTACES; DID DRIVE, OR WAS I ACTUAL PHSICAL COTROL OF A VEHICLE, WHILE UDER THE IFLUECE OF A ALCOHOLIC BEVERAGE/CHEMICAL SUBSTACE/COTROLLED SUBSTACE TO THE EXTET RMAL FACULTIES WERE LICESE UMBER COMMETS PERTAIIG TO OFFESE: (Only one offense each citation) PASSEGER < 18 EARS DAMAGE TO OTHER PROPERT IJUR TO ATHER $ COURT COURT AD LOCATIO SERIOUS BODIL IJUR TO ATHER I AGREE AD PROMISE TO COMPL AD ASWER TO THE CHARGES AD ISTRUCTIOS SPECIFIED I THIS CITATIO. WILLFUL REFUSAL TO ACCEPT AD SIG THE CITATIO MA RESULT I ARREST. I UDERSTAD M SIGATURE IS T A ADMISSIO OF GUILT OR WAIVER OF RIGHTS. IF OU EED ABLE FACILIT ACCOMDATIOS TO COMPL WITH THIS CITATIO, COTACT THE CLERK OF THE COURT. X SIGATURE OF VIOLATOR EFFECTIVE IMMEDIATEL, OUR DRIVIG PRIVILEGE IS SUSPEDED/DISQUALIFIED FOR: DRIVIG WITH A ULAWFUL BLOOD OR BREATH ALCOHOL LEVEL. THIS SUSPESIO IS FOR A PERIOD OF SIX THS IF THIS IS THE FIRST VIOLATIO OR OE EAR IF PREVIOUSL SUSPEDED FOR DRIVIG WITH A ULAWFUL BLOOD OR BREATH ALCOHOL LEVEL. IF OU HOLD A CDL OR OU ARE OPERATIG A CMV, OUR COMMERCIAL LICESE/PRIVILEGE WILL ALSO BE DISQUALIFIED FOR OE EAR FOR THE FIRST OFFESE OR PERMAETL DISQUALIFIED FOR A SUBSEQUET OFFESE. REFUSAL TO SUBMIT TO LAWFUL BREATH, BLOOD OR URIE TEST , F. S. THIS SUSPESIO IS FOR A PERIOD OF OE EAR IF THIS IS A FIRST REFUSAL OR 18 THS IF PREVIOUSL SUSPEDED FOR THIS OFFESE. IF OU HOLD A CDL OR OU ARE OPERATIG A CMV, OUR COMMERCIAL LICESE/PRIVILEGE WILL ALSO BE DISQUALIFIED FOR A PERIOD OF OE EAR FOR A FIRST REFUSAL OR PERMAETL DISQUALIFIED FOR A SUBSEQUET REFUSAL. LICESE SURREDERED? ULESS IELIGIBLE, THIS CITATIO SHALL SERVE AS A TEMPORAR LICESE AD WILL EXPIRE AT MIDIGHT O THE 10TH DA FOLLOWIG THE OF SUSPESIO. BUREAU OF ADMIISTRATIVE REVIEWS OFFICE, OU MA REQUEST, WITHI 10 DAS AFTER THE OF SUSPESIO, A REVIEW OF SUSPESIO B THE DEPARTMET OF HIGHWA SAFET AD TOR VEHICLES OR A REVIEW TO DETERMIE ELIGIBILIT FOR A RESTRICTED LICESE IF THIS IS OUR FIRST DUI RELATED OFFESE. SEE REVERSE SIDE. RAK - SIGATURE OF OFFICER BADGE. ID.. TROOP UIT FACE 3

4 3 4B 4B 2015, RR Donnelley. All rights reserved COSECUTIVE UMBERIG BARCODE PTS 1 & 4 OL FLORIDA DUI UIFORM TRAFFIC CITATIO COUT OF (IF APPLICABLE) I THE COURT DESIGATED BELOW THE UDERSIGED CERTIFIES THAT HE/SHE HAS JUST AD ABLE GROUDS TO BELIEVE AD DOES BELIEVE THAT O DA OF WEEK TH DA EAR AME (PRIT) FIRST AGEC AME AGEC # SUMS (VIOLATOR S COP) IF DIFFERET THA OE O LICESE "X" HERE TELEPHOE UMBER OF DA R RACE SEX HGT CLASS CDL LICESE R. LICESE EXP. R. VEHICLE MAKE STLE COLOR VEHICLE LICESE. TRAILER TAG. EAR TAG EXPIRES UPO A PUBLIC OR HIGHWA, OR OTHER LOCATIO, AMEL FT. MILES S E W OF DE DID ULAWFULL COMMIT THE OFFESE OF DRIVIG UDER THE IFLUECE OF ALCOHOLIC BEVERAGES, CHEMICAL OR COTROLLED SUBSTACES; DID DRIVE, OR WAS I ACTUAL PHSICAL COTROL OF A VEHICLE, WHILE UDER THE IFLUECE OF A ALCOHOLIC BEVERAGE/CHEMICAL SUBSTACE/COTROLLED SUBSTACE TO THE EXTET RMAL FACULTIES WERE LICESE UMBER COMMETS PERTAIIG TO OFFESE: (Only one offense each citation) PASSEGER < 18 EARS DAMAGE TO OTHER PROPERT IJUR TO ATHER $ COURT COURT AD LOCATIO SERIOUS BODIL IJUR TO ATHER I AGREE AD PROMISE TO COMPL AD ASWER TO THE CHARGES AD ISTRUCTIOS SPECIFIED I THIS CITATIO. WILLFUL REFUSAL TO ACCEPT AD SIG THE CITATIO MA RESULT I ARREST. I UDERSTAD M SIGATURE IS T A ADMISSIO OF GUILT OR WAIVER OF RIGHTS. IF OU EED ABLE FACILIT ACCOMDATIOS TO COMPL WITH THIS CITATIO, COTACT THE CLERK OF THE COURT. X SIGATURE OF VIOLATOR EFFECTIVE IMMEDIATEL, OUR DRIVIG PRIVILEGE IS SUSPEDED/DISQUALIFIED FOR: DRIVIG WITH A ULAWFUL BLOOD OR BREATH ALCOHOL LEVEL. THIS SUSPESIO IS FOR A PERIOD OF SIX THS IF THIS IS THE FIRST VIOLATIO OR OE EAR IF PREVIOUSL SUSPEDED FOR DRIVIG WITH A ULAWFUL BLOOD OR BREATH ALCOHOL LEVEL. IF OU HOLD A CDL OR OU ARE OPERATIG A CMV, OUR COMMERCIAL LICESE/PRIVILEGE WILL ALSO BE DISQUALIFIED FOR OE EAR FOR THE FIRST OFFESE OR PERMAETL DISQUALIFIED FOR A SUBSEQUET OFFESE. REFUSAL TO SUBMIT TO LAWFUL BREATH, BLOOD OR URIE TEST , F. S. THIS SUSPESIO IS FOR A PERIOD OF OE EAR IF THIS IS A FIRST REFUSAL OR 18 THS IF PREVIOUSL SUSPEDED FOR THIS OFFESE. IF OU HOLD A CDL OR OU ARE OPERATIG A CMV, OUR COMMERCIAL LICESE/PRIVILEGE WILL ALSO BE DISQUALIFIED FOR A PERIOD OF OE EAR FOR A FIRST REFUSAL OR PERMAETL DISQUALIFIED FOR A SUBSEQUET REFUSAL. LICESE SURREDERED? ULESS IELIGIBLE, THIS CITATIO SHALL SERVE AS A TEMPORAR LICESE AD WILL EXPIRE AT MIDIGHT O THE 10TH DA FOLLOWIG THE OF SUSPESIO. BUREAU OF ADMIISTRATIVE REVIEWS OFFICE, OU MA REQUEST, WITHI 10 DAS AFTER THE OF SUSPESIO, A REVIEW OF SUSPESIO B THE DEPARTMET OF HIGHWA SAFET AD TOR VEHICLES OR A REVIEW TO DETERMIE ELIGIBILIT FOR A RESTRICTED LICESE IF THIS IS OUR FIRST DUI RELATED OFFESE. SEE REVERSE SIDE. RAK - SIGATURE OF OFFICER BADGE. ID.. TROOP UIT FACE 4

5 5B 5B 2015, RR Donnelley. All rights reserved FLORIDA DUI UIFORM TRAFFIC CITATIO COUT OF (IF APPLICABLE) I THE COURT DESIGATED BELOW THE UDERSIGED CERTIFIES THAT HE/SHE HAS JUST AD ABLE GROUDS TO BELIEVE AD DOES BELIEVE THAT O DA OF WEEK TH DA EAR AME (PRIT) FIRST AGEC AME AGEC # OFFICER - AGEC COP IF DIFFERET THA OE O LICESE "X" HERE TELEPHOE UMBER OF DA R RACE SEX HGT CLASS CDL LICESE R. LICESE EXP. R. VEHICLE MAKE STLE COLOR VEHICLE LICESE. TRAILER TAG. EAR TAG EXPIRES UPO A PUBLIC OR HIGHWA, OR OTHER LOCATIO, AMEL FT. MILES S E W OF DE DID ULAWFULL COMMIT THE OFFESE OF DRIVIG UDER THE IFLUECE OF ALCOHOLIC BEVERAGES, CHEMICAL OR COTROLLED SUBSTACES; DID DRIVE, OR WAS I ACTUAL PHSICAL COTROL OF A VEHICLE, WHILE UDER THE IFLUECE OF A ALCOHOLIC BEVERAGE/CHEMICAL SUBSTACE/COTROLLED SUBSTACE TO THE EXTET RMAL FACULTIES WERE LICESE UMBER COMMETS PERTAIIG TO OFFESE: (Only one offense each citation) PASSEGER < 18 EARS DAMAGE TO OTHER PROPERT IJUR TO ATHER $ COURT COURT AD LOCATIO SERIOUS BODIL IJUR TO ATHER I AGREE AD PROMISE TO COMPL AD ASWER TO THE CHARGES AD ISTRUCTIOS SPECIFIED I THIS CITATIO. WILLFUL REFUSAL TO ACCEPT AD SIG THE CITATIO MA RESULT I ARREST. I UDERSTAD M SIGATURE IS T A ADMISSIO OF GUILT OR WAIVER OF RIGHTS. IF OU EED ABLE FACILIT ACCOMDATIOS TO COMPL WITH THIS CITATIO, COTACT THE CLERK OF THE COURT. X SIGATURE OF VIOLATOR EFFECTIVE IMMEDIATEL, OUR DRIVIG PRIVILEGE IS SUSPEDED/DISQUALIFIED FOR: DRIVIG WITH A ULAWFUL BLOOD OR BREATH ALCOHOL LEVEL. THIS SUSPESIO IS FOR A PERIOD OF SIX THS IF THIS IS THE FIRST VIOLATIO OR OE EAR IF PREVIOUSL SUSPEDED FOR DRIVIG WITH A ULAWFUL BLOOD OR BREATH ALCOHOL LEVEL. IF OU HOLD A CDL OR OU ARE OPERATIG A CMV, OUR COMMERCIAL LICESE/PRIVILEGE WILL ALSO BE DISQUALIFIED FOR OE EAR FOR THE FIRST OFFESE OR PERMAETL DISQUALIFIED FOR A SUBSEQUET OFFESE. REFUSAL TO SUBMIT TO LAWFUL BREATH, BLOOD OR URIE TEST , F. S. THIS SUSPESIO IS FOR A PERIOD OF OE EAR IF THIS IS A FIRST REFUSAL OR 18 THS IF PREVIOUSL SUSPEDED FOR THIS OFFESE. IF OU HOLD A CDL OR OU ARE OPERATIG A CMV, OUR COMMERCIAL LICESE/PRIVILEGE WILL ALSO BE DISQUALIFIED FOR A PERIOD OF OE EAR FOR A FIRST REFUSAL OR PERMAETL DISQUALIFIED FOR A SUBSEQUET REFUSAL. LICESE SURREDERED? ULESS IELIGIBLE, THIS CITATIO SHALL SERVE AS A TEMPORAR LICESE AD WILL EXPIRE AT MIDIGHT O THE 10TH DA FOLLOWIG THE OF SUSPESIO. BUREAU OF ADMIISTRATIVE REVIEWS OFFICE, OU MA REQUEST, WITHI 10 DAS AFTER THE OF SUSPESIO, A REVIEW OF SUSPESIO B THE DEPARTMET OF HIGHWA SAFET AD TOR VEHICLES OR A REVIEW TO DETERMIE ELIGIBILIT FOR A RESTRICTED LICESE IF THIS IS OUR FIRST DUI RELATED OFFESE. SEE REVERSE SIDE. RAK - SIGATURE OF OFFICER BADGE. ID.. TROOP UIT FACE 5

6 B- B- COMPLAIT CASE. DOCKET. PAGE. COURT ACTIO AD OTHER ORDERS BAIL FIXED AT $ OR CASH DEPOSIT OF $ SIGATURE OF PERSO GIVIG BAIL SIGATURE OF PERSO TAKIG BAIL FIE I THE AUT OF $ REQUIRED B COURT SCHEDULE. RECEIVED AS SIGATURE OF CLERK COTIUACE TO COTIUACE TO BOD ESTREATED WARRAT ISSUED VIOLATOR FAILED TO APPEAR- LICESE SUSPEDED VIOLATOR ARRAIGED O PLEA: FIDIG: ADJUDICATIO: SETECE: FIE JAILED COST DAS () IMPROVEMET SCHOOL OTHER LICESE SUSPEDED OR REVOKED FOR DAS RECOMMED LICESE SUSPESIO FOR DAS RECOMMED RE-TEST SIGATURE OF JUDGE TESTI - JUDGE S TES (OR OTHER COURT ORDERS): APPEAL BOD OF $ VIOLATOR S FIGERPRIT WHE APPLICABLE BACK 1; HEAD TO HEAD; SCREES 70%

7 B-2A B-2A FLORIDA DUI UIFORM TRAFFIC CITATIO REPORT OF DISPOSITIO ABSTRACT OF COURT RECORD FOR DEPARTMET OF HIGHWA SAFET AD TOR VEHICLES MUST BE REPORTED WITHI 10 DAS AFTER FIAL ADJUDICATIO I. COURT ACTIO DEFEDAT S PLEA: (CHECK OE) GUILT T GUILT LO COTEDERE TRIAL: 1 JUR 2 -JUR 1 DEFEDAT REPRESETED B COUSEL 2 DEFEDAT WAIVED COUSEL TOTAL FIE AUT TOTAL COURT COSTS VERDICT CHECK OL OE: II. 1 GUILT 6 ESTREATED OR FORFEITED BOD 9 ADJUDGED DELIQUET (JUVEILE OL) 2 T GUILT 3 DISMISSED 8 LLE PROSEQUI A B ADJUDICATIO WITHHELD B JUDGE OTHER EXPLAI SETECE CHECK OL WHE VERDICT IS GUILT OR ADJUDICATIO WITHHELD B JUDGE. 1 SERVED 2 SETECE WITHHELD, DEFERRED OR SUSPEDED 3 PROBATIO 4 TRAFFIC SCHOOL 5 FIE AD/OR COSTS 6 LICESE ACTIO OL EXPLAI BELOW 7 OTHER 8 COMMUIT SERVICE EXPLAI 9 ICARCERATIO (AFTER DISPOSITIO) IF ORIGIAL CHARGE IS CHAGED, ETER CHARGE OF WHICH VIOLATOR WAS COVICTED. DO T MAKE A ADDITIOAL CHAGES O FROT OR BACK OF THIS CITATIO. ORIGIAL DUI CHARGE CHAGED PER ATTORE III. LOCATIO COUT PRESIDIG JUDGE LOCATIO OF TRIAL COURT TPE OF COURT (CHECK BOX) 1 COUT 2 CIRCUIT IV. LICESE ACTIO COURT RECOMMEDS THE DEPARTMET SUSPED DRIVIG PRIVILEGE LEGTH VIOLATIOS CARRIG MADATOR REVOCATIOS COURT MA SPECIF LEGTH OR CHECK OE: MIIMUM MAXIMUM LICESE PICKED UP B COURT AD ATTACHED TO THIS REPORT AS REQUIRED B F.S VIOLATOR S ABILIT TO DRIVE IS QUESTIOABLE AD COURT RECOMMEDS IATIO. V. THE S BELOW MUST BE ETERED O ALL DISPOSITIOS FIAL ADJUDICATIO OR ACTIO O SUBMITTED TO DHSMV O SIGATURE OF IDIVIDUAL SUBMITTIG REPORT BACK 2; HEAD TO HEAD; SCREES 70%

8 B-4A B-4A Information Regarding Review Hearing FIAL ORDER This will serve as notice of final order of license suspension/disqualification effective on the date it was issued to you. ou may, request a formal or informal review of the suspension/disqualification, or if this is your first DUI related offense, you may waive the review and request a review to determine eligibility for a restricted license. If you want the department to conduct a review of your suspension/disqualification you must request such review at the location indicated on the reverse side. our request must be submitted in writing within ten calendar days after the date of suspension/disqualification and include a copy of this notice. When requesting a review, or if this is your first DUI related offense and you wish to waive the review and request an eligibility review for a restricted license, you must include a non-refundable filing fee of $25 made payable to DHSMV. REVIEW PROCESSES The informal review shall consist solely of an examination of the materials submitted by you and the law enforcement officer or correctional officer. The formal review allows you to be heard and present witnesses in regard to this suspension/disqualification. WAIVER OF FORMAL/IFORMAL REVIEW If this is your first DUI related offense and you otherwise qualify, you may waive your right to a review of the suspension and receive a business purpose only license for use during the period your driver license is suspended. A non-refundable filing fee of $25 made payable to DHSMV is required for determination of your eligibility for a restricted license. DRIVIG WITH A ULAWFUL BLOOD OR BREATH ALCOHOL LEVEL (.08 OR ABOVE) 1. Whether the law enforcement officer had probable cause to believe that the person was driving or in actual physical control of a motor vehicle in this state while under the influence of alcoholic beverages or controlled substances (DUI). 2. Whether the person had an unlawful blood or breath alcohol level (.08 or above). REFUSAL TO SUBMIT TO A BREATH, BLOOD OR URIE TEST 1. Same as number one above. 2. Whether the person refused to submit to any such test after being requested to do so by a law enforcement officer or correctional officer. 3. Whether the person whose license was suspended was told that if he or she refused to submit to such test his or her privilege to operate a motor vehicle would be suspended. I CASE OF A DISQUALIFICATIO THE FOLLOWIG ISSUES WILL BE COSIDERED: DRIVIG WITH A ULAWFUL BLOOD OR BREATH ALCOHOL LEVEL (.08 OR ABOVE) 1. Whether the arresting law enforcement officer had probable cause to believe that the person was driving or in actual physical control of a commercial motor vehicle, or any motor vehicle if the driver holds a commercial driver s license, in this state while he or she had any alcohol, chemical substances, or controlled substances in his or her body. 2. Whether the person had an unlawful blood-alcohol level of 0.08 or higher. REFUSAL TO SUBMIT TO A BREATH, BLOOD OR URIE TEST 1. Same as number one above. 2. Whether the person refused to submit to any such test after being requested to do so by a law enforcement or correctional officer. 3. Whether the person was told that if he or she refused to submit to such test his or her driving privilege to operate a commercial motor vehicle would be disqualified. FAILURE TO REQUEST A REVIEW WITHI THE 10 DA PERIOD SHALL RESULT I THE WAIVER OF OUR RIGHT TO A REVIEW OF THE SUSPESIO/DISQUALIFICATIO AD A REVIEW OF OUR ELIGIBILIT FOR A RESTRICTED LICESE. Location of Administrative Reviews Hearing Offices 1. Clearwater th Avenue orth, Suite Daytona Beach Orange Avenue 3. Ft. Myers Evans Avenue, Suite Ft. Pierce South Federal Hwy., Suite 8 5. Gainesville W. 13th Street, Suite Jacksonville Wilson Blvd. 7. Lantana West Lantana Rd 8. Lauderdale Lakes W. Oakland Park Blvd 9. Miami West Flagler Street, Suite 82C 10. Melbourne S. Babcock Street 11. Panama City West 15th Street (Lincoln Center) 12. Pensacola Stumpfield Road 13. Tallahassee Apalachee Parkway, Rm B141, MS Tampa East Hillsborough Avenue 15. Orlando Clarcona-Ocoee Road, Ste Winter Springs Tuscawilla Road, Suite 1368 BACK 4; HEAD TO HEAD; SCREES 70%

9 B-5A B-5A REPORT OF ACTIO O CASE VIOLATIOS BUREAU: Date Amt. of Fine Paid $ Costs $ COURT ACTIO: Date Disposition Plea Amt. of Fine Paid $ License Action Costs $ OFFICER S TES FOR TESTIFIG I COURT: PLEASE TE FACTS AD CIRCUMSTACES I ADDITIO TO THOSE CHECKED O FACE OF COMPLAIT - THAT IS: 1. A SPECIFIC ACTIO OF VIOLATOR WHICH ICREASED THE HAZARD OF THE VIOLATIO; 2. WHERE VIOLATIO OBSERVED AD COTACT MADE; 3. TOTAL DISTACE TRAVELED DURIG PURSUIT; 4. METS B VIOLATOR AD GEERAL ATTITUDE; AD 5. PLACE OF EMPLOMET. SLIPPER PAVEMET DARKESS OTHER TRAFFIC PRESET WITESSES: Wet Rain ight CAUSED PERSO TO DODGE? es o PD PI Fatal Fog Driver Ped. Vehicle Rain Pedestrian Hit fixed Object Unlighted JUST Right Angle Cross MISSED Head On Oncoming Side Swipe Pedestrian B APPROX. Rear End Same Ran off Roadway Direction FT. Intersection HIGHWA TPE 2 Lane 3 Lane 4 Lane 4 Lane Divided AREA: Rural Residential School Industrial Business Service Brake Parking Brake Headlights Tail Lights Stop Lights Windshield Wiper Horn Tires Other VEHICLE DEFECTS BACK 5; HEAD TO HEAD; SCREES 70%