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File No. STATE OF NORTH CAROLINA County In The General Court Of JusticeDistrict Court Division ATTACH TEST RECORD TICKET HERE NOTE TO OFFICER: The officer should review and follow the instructions on Side Two of this form. NOTE: A “commercial motor vehicle” is as defined in G.S. 20-4.01(3d). Name AddressCity State Drivers License No. State Vehicle Type CMVHaz. Mat. Citation No. Zip Race Date Of Birth Sex IN THE MATTER OF Law Enforcement Officer/Analyst Copy The undersigned being first duly sworn says: 1. I am a law enforcement officer . On the day of \ , , at (a.)(p.)m., a law enforcement officer had reasonable grounds to believe the above named person, hereinafter referred to as driver, operated a vehicle ( commercial motor vehicle) in the above named county upon (Give Street, Highway, Or Public Vehicular Area) while committing an implied-consent offense in that . (List Sufficient Facts To Establish Probable Cause) 2. The driver has a drivers license restriction: alcohol concentration. ignition interlock. conditional restoration (Restr: *9) . 3. The driver violated a drivers license restriction by: refusing to be transported for testing. not having an operable ignition interlock on the vehicle being driven. failing to personally activate the ignition interlock on the vehicle being driven. exceeding the driver’s alcohol concentration limitation. refusing a chemical analysis (if refusal, also complete items no. 14 and 15 below, as appropriate for this case) . 4. The driver was charged with the implied-consent of fense of: G.S. 20-138.1. Other: . 4a. The driver has one or more pending of fenses in the following county(ies) for which the drivers license had been or is revoked under G.S. 20-16.5. 5. After the driver was charged, I took the driver before , a chemical analyst authorized to administer a test of the driver’s breath. 6. I am a chemical analyst and possess a current permit issued by the Department of Health and Human Services authorizing me to conduct chemical analyses of the breath utilizing the Intox EC/IR II. 7. I informed the driver orally and also gave notice in writing of the rights specified in G.S. 20-16.2(a). I completed informing the driver of the rights as indicated on the attached DHHS 4081. 8. I began observing the driver for the purpose of complying with the observation period requirements for a breath analysis in accordance with the methods/rules approved by the Department of Health and Human Services at (a.)(p.)m. on the day of , \ . 9. On the day of \ , , at (a.)(p.)m., I requested the driver to submit to a chemical analysis of his/her breath or blood or urine. 10. The driver was unconscious or otherwise incapable of refusal an d therefore the notification of rights and request to submit to a chemical analysis were not made. I directed the taking of a blood sample by a person qualified under G.S. 20-139.1 based on the (check one) AOC-CR-155 search warrant issued and executed in this case. totality of the circumstances, which demonstrated an exigency that justified the taking of the sample without first obtaining a search warrant. 11. The driver submitted to a chemical analysis of his/her breath. I administered the chemical analysis to the driver in accordance with the methods/ rules approved by the Department of Health and Human Services using an Intox EC/IR II, and it printed the results of the driver’s chemical analysis on the attached test record, DHHS 4082, which is made part of this Affidavit. The most recent preventive maintenance was performed on this Intox EC/IR II on the day of \ , , as shown on the preventive maintenance record. I provided the driver with a copy of the attached test record before any trial or proceeding in which the results of the chemical analysis may be used. 12. The chemical analysis of the driver ’s breath indicated an alcohol concentration of 0.15 or more. 13. The driver consented to the obtaining of a sample of his/her bl ood or urine for a chemical analysis, which was collected as indicated on the attached DHHS 4081. 14. The driver willfully refused to submit to a chemical analysis as indicat\ ed on the attached DHHS 4082. DHHS 4081. The willful refusal occurred in an implied-consent offense involving death or critical injury to another person. 15. After the driver ’s willful refusal, a blood sample was obtained based on the (check one) AOC-CR-155 search warrant issued and executed in this case. totality of the circumstances, which demonstrated an exigency that justified the taking of the sample without first obtaining a search warrant. Date Signature Of Official Authorized To Administer Oaths Signature Of Chemical Analyst/Law Enforcement Officer Print Name Of Chemical Analyst/Law Enforcement Officer Agency Name DHHS Permit No. Date My Commission Expires County Where Notarized SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME Deputy CSC Magistrate Assistant CSC Clerk Of Superior Court Notary SEAL AFFIDAVIT AND REVOCATION REPORT OF LAW ENFORCEMENT OFFICER CHEMICAL ANALYST The charged offense is impaired supervision or instruction under G.S. 20-12.1. Accordingly, substitute “supervisor/instructor” wherever “driver” appears below. G.S. 20-16.2, 20-16.5, 20-17.8, 20-19(c3), 20-139.1 AOC-CVR-1A/DHHS 3907, Rev. 12/17