DI-93 rev 09-21.pdf

BTH TEST OPR NO LEIN ENTRY RECORD SEQUENCE NO

DI-93 (09/21) By the authority of P.A. 300 of 1949 as amended

OFFICER’S REPORT OF REFUSAL TO SUBMIT TO CHEMICAL TEST

PERSON’S FULL NAME (AS APPEARS ON MICHIGAN DRIVER’S LICENSE)

ADDRESS (NUMBER & STREET)

CITY STATE ZIP

HEIGHT WEIGHT EYE COLOR HAIR COLOR

BIRTH DATE (MM/DD/YY) SEX

MALE FEMALE

MICHIGAN DRIVER’S LICENSE NUMBER

OTHER STATE DRIVER’S LICENSE NUMBER STATE

h OPERATOR h CHAUFFEUR h MOPED

ARREST DATE (MM/DD/YY) MILITARY TIME REFUSAL DATE (MM/DD/YY) MILITARY TIME

COUNTY (OF ARREST) CITY OR TOWNSHIP (OF ARREST) CO/CTY/TWP CODE

*VEHICLE TYPE INSTRUMENT # BAC #1 BAC #2 BAC #3 UCR CODE COMPLAINT NUMBER

ARRESTING OFFICER’S NAME BADGE NUMBER ORI NUMBER

BREATH TEST OPERATOR’S NAME, only if not listed above and necessary for hearing BADGE NUMBER ORI NUMBER

OTHER OFFICER, if necessary for hearing BADGE NUMBER ORI NUMBER

Was person involved in an accident? REFUSED N/A N/A N/A

YES NO

The above named person was arrested for a violation of section 625(1), (3), (4), (5), (6), (7), (8), 625a(5) or 625m of the Michigan Vehicle Code, as amended, or a local ordinance substantially corresponding to section 625(1), (3), (4), (5), (6), (7), (8), 625a(5) or 625m or for the offense of manslaughter, murder, reckless driving causing death, reckless driving causing serious impairment of a body function, moving violation causing death, or moving violation causing serious impairment of a body function resulting from the operation of a motor vehicle.

The officer had reasonable grounds to believe that the above named person violated section 625(1), (3), (4), (5), (6), (7), (8), 625a(5) or 625m of the Michigan Vehicle Code, as amended, or local ordinance substantially corresponding to section 625(1), (3), (4), (5), (6), (7), (8), 625a(5) or 625m or committed the offense of manslaughter, murder, reckless driving causing death, reckless driving causing serious impairment of a body function, moving violation causing death, or moving violation causing serious impairment of a body function resulting from the operation of a motor vehicle while impaired by or under the influence of alcoholic liquor, a controlled substance, other intoxicating substance, or a combination, or while having an unlawful alcohol content, or if the person is less that 21 years of age while having any alcohol content. [MCL 257.625c(1)(b)]

The above named person was requested to take a chemical test. The person was advised of the chemical test rights as required under section 625a and refused to take a chemical test.

License confiscated? c c License destroyed? c c Under 21? c c

SERVICE OF NOTICE OF SUSPENSION

I certify that I hand delivered a copy of the document containing the Notice of Suspension and Appeal Rights to the person named above.

Officer’s Signature_______________________________________________________ Date (MM/DD/YY)___________________________________

OFFICER’S INSTRUCTIONS

Give two white copies to person Keep two pink copies

REQUEST FOR HEARING

Driver’s Copy to Request Hearing

I request a hearing before the Office of Hearings and Administrative Oversight to contest issues number(s)._______________ (Issues are listed on the Notice of Suspension.)

Affirmative Address Statement:

c The address on my master driving record is correct. Send all correspondence to this address.

c The address on the reverse side is only a temporary address. Send all correspondence to this address.

Please DO NOT CHANGE the address on my master driving record file.

If you need to inform the Department of State of a permanent address change you may change your address on-line, by mail or in person.

Online: A change of address may be submitted through Michigan.gov/SOS.

By Mail: The form to change your address can be obtained from Michigan.gov/SOS.

In Person: If you are changing your address at a branch office, be sure to bring your driver’s license or state ID card.

Signature________________________________________________________Date____________________________

Driver’s License Number____________________________________________Telephone_______________________

This request for hearing must be mailed within 14 days of the receipt of the Officer’s Report Of Refusal to Submit to Chemical Test containing Notice of Suspension, or your operator’s or chauffeur’s license and vehicle group designation or operating privilege will be suspended. Send this form. Do not send a photocopy.

Mail to: MICHIGAN DEPARTMENT OF STATE

OFFICE OF HEARINGS AND ADMINISTRATIVE OVERSIGHT

P O BOX 30196

LANSING MI 48909-7696

DI-93 (09/21)

Request For Hearing:

OFFICER’S REPORT OF REFUSAL TO SUBMIT TO CHEMICAL TEST

PERSON’S FULL NAME (AS APPEARS ON MICHIGAN DRIVER’S LICENSE)

ADDRESS (NUMBER & STREET)

CITY STATE ZIP

HEIGHT WEIGHT EYE COLOR HAIR COLOR

BIRTH DATE (MM/DD/YY) SEX

MALE FEMALE

MICHIGAN DRIVER’S LICENSE NUMBER

OTHER STATE DRIVER’S LICENSE NUMBER STATE

h OPERATOR h CHAUFFEUR h MOPED

ARREST DATE (MM/DD/YY) MILITARY TIME REFUSAL DATE (MM/DD/YY) MILITARY TIME

COUNTY (OF ARREST) CITY OR TOWNSHIP (OF ARREST) CO/CTY/TWP CODE

*VEHICLE TYPE INSTRUMENT # BAC #1 BAC #2 BAC #3 UCR CODE COMPLAINT NUMBER

ARRESTING OFFICER’S NAME BADGE NUMBER ORI NUMBER

BREATH TEST OPERATOR’S NAME, only if not listed above and necessary for hearing BADGE NUMBER ORI NUMBER

OTHER OFFICER, if necessary for hearing BADGE NUMBER ORI NUMBER

Was person involved in an accident? REFUSED N/A N/A N/A

YES NO

The above named person was arrested for a violation of section 625(1), (3), (4), (5), (6), (7), (8), 625a(5) or 625m of the Michigan Vehicle Code, as amended, or a local ordinance substantially corresponding to section 625(1), (3), (4), (5), (6), (7), (8), 625a(5) or 625m or for the offense of manslaughter, murder, reckless driving causing death, reckless driving causing serious impairment of a body function, moving violation causing death, or moving violation causing serious impairment of a body function resulting from the operation of a motor vehicle.

The officer had reasonable grounds to believe that the above named person violated section 625(1), (3), (4), (5), (6), (7), (8), 625a(5) or 625m of the Michigan Vehicle Code, as amended, or local ordinance substantially corresponding to section 625(1), (3), (4), (5), (6), (7), (8), 625a(5) or 625m or committed the offense of manslaughter, murder, reckless driving causing death, reckless driving causing serious impairment of a body function, moving violation causing death, or moving violation causing serious impairment of a body function resulting from the operation of a motor vehicle while impaired by or under the influence of alcoholic liquor, a controlled substance, other intoxicating substance, or a combination, or while having an unlawful alcohol content, or if the person is less that 21 years of age while having any alcohol content. [MCL 257.625c(1)(b)]

The above named person was requested to take a chemical test. The person was advised of the chemical test rights as required under section 625a and refused to take a chemical test.

License confiscated? c c License destroyed? c c Under 21? c c

SERVICE OF NOTICE OF SUSPENSION

I certify that I hand delivered a copy of the document containing the Notice of Suspension and Appeal Rights to the person named above.

Officer’s Signature_______________________________________________________ Date (MM/DD/YY)___________________________________

MICHIGAN TEMPORARY DRIVING PERMIT

This temporary driving permit is valid only if you have a valid Michigan operator’s or chauffeur’s license. If your license has a CDL and/or endorsement or restrictions, this permit grants you the same CDL and/or endorsements or restrictions. You may not apply for a replacement photo license. This permit is valid until the criminal charges are dismissed or you are acquitted, or your license or permit is suspended, restricted, or revoked for a conviction. [MCL257.625g(3)]

OFFICER’S INSTRUCTIONS

Give two white copies to person Keep two pink copies

MICHIGAN TEMPORARY DRIVING PERMIT

This permit is only valid if you have a valid Michigan driver’s license.

This permit is not valid if you are unlicensed or your license is expired, suspended, revoked or denied.

Carry this permit when driving.

DRIVER’S COPY

Notice of Suspension You have allegedly refused to take a chemical test. Your Michigan operator’s or chauffeur’s license, vehicle group designation or operating privilege will be suspended and six points will be added to your driving record.

Appeal Rights:

If you do not appeal within 14 days your operator’s or chauffeur’s license, vehicle group designation or operating privilege will be automatically suspended. If you wish to request a hearing you must do so within 14 days of the date of service of this Notice of Suspension.

Hearing Issues:

MCL 257.625f limits the issues appealable at a hearing ONLY to the following:

1. Whether the peace officer had reasonable grounds to believe that you committed a crime described in MCL 257.625c(1).

2. Whether you were placed under arrest for a crime described in MCL 257.625c(1).

3. If you refused to submit to a chemical test upon the request of the officer, whether the refusal was reasonable.

4. Whether you were advised of your rights under MCL 257.625a.

To request a hearing, complete the attached Request for Hearing and mail to the Department of State within 14 days of the date of the service of this notice.

You are not required to have an attorney at this hearing, but an attorney may represent you if you wish.

CHEMICAL TEST RIGHTS

(As read by peace officer)

I am requesting that you take a chemical test to check for alcohol and/or controlled substances or other intoxicating substance in your body. IF YOU WERE ASKED TO TAKE OR TOOK A

PRELIMINARY BREATH TEST BEFORE YOUR ARREST, YOU MUST STILL TAKE THE TEST I AM

OFFERING YOU.

If you refuse to take this chemical test, it will not be given without a court order, but I may seek to obtain such a court order. Your refusal to take this test shall result in the suspension of your operator’s or chauffeur’s license and vehicle group designation or operating privilege, and the addition of six points to your driving record.

After taking my chemical test, you have a right to demand that a person of your own choosing administer a breath, blood, or urine test. You will be given a reasonable opportunity for such a test.

You are responsible for obtaining a chemical analysis of a test sample taken by a person of your own choosing.

The results of both chemical tests shall be admissible in a judicial proceeding, and will be considered with other admissible evidence in determining your innocence or guilt.

OFFICER’S REPORT OF REFUSAL TO SUBMIT TO CHEMICAL TEST

PERSON’S FULL NAME (AS APPEARS ON MICHIGAN DRIVER’S LICENSE)

ADDRESS (NUMBER & STREET)

CITY STATE ZIP

HEIGHT WEIGHT EYE COLOR HAIR COLOR

BIRTH DATE (MM/DD/YY) SEX

MALE FEMALE

MICHIGAN DRIVER’S LICENSE NUMBER

OTHER STATE DRIVER’S LICENSE NUMBER STATE

h OPERATOR h CHAUFFEUR h MOPED

ARREST DATE (MM/DD/YY) MILITARY TIME REFUSAL DATE (MM/DD/YY) MILITARY TIME

COUNTY (OF ARREST) CITY OR TOWNSHIP (OF ARREST) CO/CTY/TWP CODE

*VEHICLE TYPE INSTRUMENT # BAC #1 BAC #2 BAC #3 UCR CODE COMPLAINT NUMBER

ARRESTING OFFICER’S NAME BADGE NUMBER ORI NUMBER

BREATH TEST OPERATOR’S NAME, only if not listed above and necessary for hearing BADGE NUMBER ORI NUMBER

OTHER OFFICER, if necessary for hearing BADGE NUMBER ORI NUMBER

Was person involved in an accident? REFUSED N/A N/A N/A

YES NO

The above named person was arrested for a violation of section 625(1), (3), (4), (5), (6), (7), (8), 625a(5) or 625m of the Michigan Vehicle Code, as amended, or a local ordinance substantially corresponding to section 625(1), (3), (4), (5), (6), (7), (8), 625a(5) or 625m or for the offense of manslaughter, murder, reckless driving causing death, reckless driving causing serious impairment of a body function, moving violation causing death, or moving violation causing serious impairment of a body function resulting from the operation of a motor vehicle.

The officer had reasonable grounds to believe that the above named person violated section 625(1), (3), (4), (5), (6), (7), (8), 625a(5) or 625m of the Michigan Vehicle Code, as amended, or local ordinance substantially corresponding to section 625(1), (3), (4), (5), (6), (7), (8), 625a(5) or 625m or committed the offense of manslaughter, murder, reckless driving causing death, reckless driving causing serious impairment of a body function, moving violation causing death, or moving violation causing serious impairment of a body function resulting from the operation of a motor vehicle while impaired by or under the influence of alcoholic liquor, a controlled substance, other intoxicating substance, or a combination, or while having an unlawful alcohol content, or if the person is less that 21 years of age while having any alcohol content. [MCL 257.625c(1)(b)]

The above named person was requested to take a chemical test. The person was advised of the chemical test rights as required under section 625a and refused to take a chemical test.

License confiscated? c c License destroyed? c c Under 21? c c

SERVICE OF NOTICE OF SUSPENSION

I certify that I hand delivered a copy of the document containing the Notice of Suspension and Appeal Rights to the person named above.

Officer’s Signature_______________________________________________________ Date (MM/DD/YY)___________________________________

MICHIGAN TEMPORARY DRIVING PERMIT

This temporary driving permit is valid only if you have a valid Michigan operator’s or chauffeur’s license. If your license has a CDL and/or endorsement or restrictions, this permit grants you the same CDL and/or endorsements or restrictions. You may not apply for a replacement photo license. This permit is valid until the criminal charges are dismissed or you are acquitted, or your license or permit is suspended, restricted, or revoked for a conviction. [MCL257.625g(3)]

Notice to the officer:

Complete this form to record implied consent refusals, including most search warrants. (See DI-177) Confiscate and destroy arrested person’s Michigan driver’s license or permit. Do Not confiscate the out of state licenses.

Input arrest data into LEIN Alcohol File (F Breath Screen) Note: This LEIN data is a continuation of the written report prescribed and furnished by the Secretary of the Sate. The encoded information will print at the

Secretary of State office and will include the following statement, “The officer had reasonable grounds to believe that the person had committed a crime described in section 625c(1), and that the person had refused to submit to the test upon the request of the peace officer and had been advised of the consequences of the refusal” as required by section 625d.

OFFICER’S INSTRUCTIONS

Give two white copies to person Keep two pink copies

OFFICER’S COPY

I am a peace officer. You are under arrest for the offense of: (Read only the charge that applies)

• Operating a vehicle while intoxicated due to the consumption of alcoholic liquor, a controlled substance, other intoxicating substance or a combination.

• Operating a vehicle while visibly impaired due to the consumption of alcoholic liquor, a controlled substance, other intoxicating substance or a combination.

• Operating with any presence of schedule 1 drugs or cocaine.

• Causing the death of another while operating a vehicle while intoxicated, or while visibly impaired by alcoholic liquor, a controlled substance, other intoxicating substance or a combination, or with an unlawful alcohol content.

• Causing serious injury to another while operating a vehicle intoxicated, or while visibly impaired by alcoholic liquor, a controlled substance, other intoxicating substance or a combination, or with an unlawful alcohol content.

• Operating a commercial motor vehicle with alcohol content of 0.04 grams or more but less than

0.08 grams per 100 milliliters of blood, per 210 liter of breath, or per 67 milliliters of urine.

• Operating a vehicle while less than 21 years of age and having any alcohol content.

• Murder resulting from the operation of a motor vehicle.

• Manslaughter resulting from the operation of a motor vehicle.

• Reckless driving causing death.

• Reckless driving causing serious impairment of a body function.

• Moving violation causing death.

• Moving violation causing serious impairment of a body function.

• Refusing a Preliminary Breath Test if arrested while operating a commercial motor vehicle.

• Endangerment (Operating while intoxicated or while visibly impaired with person under age of 16.)

CHEMICAL TEST RIGHTS

Read the rights that follow in their entirety.

I am requesting that you take a chemical test to check for alcohol and/or controlled substances or other intoxicating substance in your body. IF YOU WERE ASKED TO TAKE OR TOOK A

PRELIMINARY BREATH TEST BEFORE YOUR ARREST, YOU MUST STILL TAKE THE TEST I AM

OFFERING YOU.

If you refuse to take this chemical test, it will not be given without a court order, but I may seek to obtain such a court order. Your refusal to take this test shall result in the suspension of your operator’s or chauffeur’s license and vehicle group designation or operating privilege, and the addition of six points to your driving record.

After taking my chemical test, you have a right to demand that a person of your own choosing administer a breath, blood, or urine test. You will be given a reasonable opportunity for such a test.

You are responsible for obtaining a chemical analysis of a test sample taken by a person of your own choosing.

The results of both chemical tests shall be admissible in a judicial proceeding, and will be considered with other admissible evidence in determining your innocence or guilt.

Will you take a: (Select the appropriate test from the following list) Breath Test? or *Blood Test? or Urine Test?

*MCL 257.625c(2) provides that a person afflicted with hemophilia, diabetes, or a condition requiring the use of an anticoagulant shall not be considered to have given consent to the withdrawal of blood.

OFFICER’S REPORT OF REFUSAL TO SUBMIT TO CHEMICAL TEST

PERSON’S FULL NAME (AS APPEARS ON MICHIGAN DRIVER’S LICENSE)

ADDRESS (NUMBER & STREET)

CITY STATE ZIP

HEIGHT WEIGHT EYE COLOR HAIR COLOR

BIRTH DATE (MM/DD/YY) SEX

MALE FEMALE

MICHIGAN DRIVER’S LICENSE NUMBER

OTHER STATE DRIVER’S LICENSE NUMBER STATE

h OPERATOR h CHAUFFEUR h MOPED

ARREST DATE (MM/DD/YY) MILITARY TIME REFUSAL DATE (MM/DD/YY) MILITARY TIME

COUNTY (OF ARREST) CITY OR TOWNSHIP (OF ARREST) CO/CTY/TWP CODE

*VEHICLE TYPE INSTRUMENT # BAC #1 BAC #2 BAC #3 UCR CODE COMPLAINT NUMBER

ARRESTING OFFICER’S NAME BADGE NUMBER ORI NUMBER

BREATH TEST OPERATOR’S NAME, only if not listed above and necessary for hearing BADGE NUMBER ORI NUMBER

OTHER OFFICER, if necessary for hearing BADGE NUMBER ORI NUMBER

Was person involved in an accident? REFUSED N/A N/A N/A

YES NO

The above named person was arrested for a violation of section 625(1), (3), (4), (5), (6), (7), (8), 625a(5) or 625m of the Michigan Vehicle Code, as amended, or a local ordinance substantially corresponding to section 625(1), (3), (4), (5), (6), (7), (8), 625a(5) or 625m or for the offense of manslaughter, murder, reckless driving causing death, reckless driving causing serious impairment of a body function, moving violation causing death, or moving violation causing serious impairment of a body function resulting from the operation of a motor vehicle.

The officer had reasonable grounds to believe that the above named person violated section 625(1), (3), (4), (5), (6), (7), (8), 625a(5) or 625m of the Michigan Vehicle Code, as amended, or local ordinance substantially corresponding to section 625(1), (3), (4), (5), (6), (7), (8), 625a(5) or 625m or committed the offense of manslaughter, murder, reckless driving causing death, reckless driving causing serious impairment of a body function, moving violation causing death, or moving violation causing serious impairment of a body function resulting from the operation of a motor vehicle while impaired by or under the influence of alcoholic liquor, a controlled substance, other intoxicating substance, or a combination, or while having an unlawful alcohol content, or if the person is less that 21 years of age while having any alcohol content. [MCL 257.625c(1)(b)]

The above named person was requested to take a chemical test. The person was advised of the chemical test rights as required under section 625a and refused to take a chemical test.

License confiscated? c c License destroyed? c c Under 21? c c

SERVICE OF NOTICE OF SUSPENSION

I certify that I hand delivered a copy of the document containing the Notice of Suspension and Appeal Rights to the person named above.

Officer’s Signature_______________________________________________________ Date (MM/DD/YY)___________________________________

MICHIGAN TEMPORARY DRIVING PERMIT

This temporary driving permit is valid only if you have a valid Michigan operator’s or chauffeur’s license. If your license has a CDL and/or endorsement or restrictions, this permit grants you the same CDL and/or endorsements or restrictions. You may not apply for a replacement photo license. This permit is valid until the criminal charges are dismissed or you are acquitted, or your license or permit is suspended, restricted, or revoked for a conviction. [MCL257.625g(3)]

OFFICER’S INSTRUCTIONS

Give two white copies to person Keep two pink copies

Officer’s Copy for OHAO Hearing

I am a peace officer. You are under arrest for the offense of: (Read only the charge that applies)

• Operating a vehicle while intoxicated due to the consumption of alcoholic liquor, a controlled substance, other intoxicating substance or a combination.

• Operating a vehicle while visibly impaired due to the consumption of alcoholic liquor, a controlled substance, other intoxicating substance or a combination.

• Operating with any presence of schedule 1 drugs or cocaine.

• Causing the death of another while operating a vehicle while intoxicated, or while visibly impaired by alcoholic liquor, a controlled substance, other intoxicating substance or a combination, or with an unlawful alcohol content.

• Causing serious injury to another while operating a vehicle intoxicated, or while visibly impaired by alcoholic liquor, a controlled substance, other intoxicating substance or a combination, or with an unlawful alcohol content.

• Operating a commercial motor vehicle with alcohol content of 0.04 grams or more but less than

0.08 grams per 100 milliliters of blood, per 210 liter of breath, or per 67 milliliters of urine.

• Operating a vehicle while less than 21 years of age and having any alcohol content.

• Murder resulting from the operation of a motor vehicle.

• Manslaughter resulting from the operation of a motor vehicle.

• Reckless driving causing death.

• Reckless driving causing serious impairment of a body function.

• Moving violation causing death.

• Moving violation causing serious impairment of a body function.

• Refusing a Preliminary Breath Test if arrested while operating a commercial motor vehicle.

• Endangerment (Operating while intoxicated or while visibly impaired with person under age of 16.)

CHEMICAL TEST RIGHTS

Read the rights that follow in their entirety.

I am requesting that you take a chemical test to check for alcohol and/or controlled substances or other intoxicating substance in your body. IF YOU WERE ASKED TO TAKE OR TOOK A

PRELIMINARY BREATH TEST BEFORE YOUR ARREST, YOU MUST STILL TAKE THE TEST I AM

OFFERING YOU.

If you refuse to take this chemical test, it will not be given without a court order, but I may seek to obtain such a court order. Your refusal to take this test shall result in the suspension of your operator’s or chauffeur’s license and vehicle group designation or operating privilege, and the addition of six points to your driving record.

After taking my chemical test, you have a right to demand that a person of your own choosing administer a breath, blood, or urine test. You will be given a reasonable opportunity for such a test.

You are responsible for obtaining a chemical analysis of a test sample taken by a person of your own choosing.

The results of both chemical tests shall be admissible in a judicial proceeding, and will be considered with other admissible evidence in determining your innocence or guilt.

Will you take a: (Select the appropriate test from the following list) Breath Test? or *Blood Test? or Urine Test?

*MCL 257.625c(2) provides that a person afflicted with hemophilia, diabetes, or a condition requiring the use of an anticoagulant shall not be considered to have given consent to the withdrawal of blood.