| 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#) |
|