Sec. 16. The bureau certificate must contain the following information and may be substantially in the following form:
BUREAU OF MOTOR VEHICLES
CERTIFICATE
Date of Arrest
Time
Driver's License No.
License State
a.m.
/ /
p.m.
Name: (first)
(M.I.)
(last)
Date of Birth
/ /
CURRENT Address (street, city, state, zip)
Court Code
Cause Number
Sex
Weight
Height
Eyes
Hair
The above motorist
BUREAU USE ONLY
REFUSED alcohol test
FAILED alcohol test 0.%
Court Determination
It has been determined there was probable cause the defendant violated IC 9-30-5 this ___________ day of ________________, 20__ and that charges are pending herein.
_____________________ Court
______________________ County
____________________________
Judge's Signature