APPENDIX E
Florida Implied Consent Warning

IMPLIED CONSENT WARNING
STATE OF FLORIDA

DEFENDANT’S NAME AGENCY CASE NUMBER

BREATH TEST
I am now requesting that you submit to an approved test of your breath for the purpose of determining the alcoholic content of your breath.

OR

URINE TEST
I am now requesting that you submit to a test of your urine for the purpose of determining the presence of any chemical or controlled substance.

OR

BLOOD TEST
I am now requesting that you submit to an approved test of your blood for the purpose of determining its alcoholic content and/or the presence of any chemical or controlled substance.

Will you take the test?     □ YES □ NO

If you fail to submit to the test I have requested of you, your privilege to operate a motor vehicle will be suspended for a period of one (1) year for a first refusal, or eighteen (18) months if your privilege has been previously suspended as a result of a refusal to submit to a lawful test of your breath, urine or blood. Additionally, if you refuse to submit to the test I have requested of you and if your driving privilege has been previously suspended for a prior refusal to submit to a lawful test of your breath, urine or blood, you will be committing a misdemeanor. Refusal to submit to the test I have requested of you is admissible into evidence in any criminal proceeding.

Do you still refuse to submit to this test knowing that your driving privilege will be suspended for a period of at least one year and that you will be charged criminally for a subsequent refusal?
□ YES □ NO

DATE TIME DEFENDANT’S SIGNATURE (YOUR SIGNATURE IS NOT AN ADMISSION OF GUILT)
ARRESTING OFFICER (PRINT NAME AND ID#) BREATH TEST OPERATOR (PRINT NAME AND ID#)