FOR MOTOR VEHICLE OPERATORS (N.J.S.A. 39:4-50.2(e))
(revised & effective July 1, 2012)
Enter Defendant’s Name ______________________________________
The police officer shall read the following:
1. You have been arrested for driving while intoxicated. N.J.S.A. 39:4-50.
2. The law requires you to submit samples of your breath for the purpose of testing to determine
3. A record of the taking of the breath samples, including the test results, will be made. Upon your request, a copy of that record will be made available to you.
4. After you have provided samples of your breath for testing, you have the right, at your own expense, to have a person or physician of your own selection take independent samples of your breath, blood or urine for independent testing.
5. If you refuse to provide samples of your breath, you will be issued a separate summons for the refusal. A court may find you guilty of both refusal and driving while intoxicated.
6. If a court finds you guilty of the refusal, you will be subject to various penalties, including license
revocation of up to 20 years, a fine of up to $2000, installation of an ignition interlock, and referral to an Intoxicated Driver Resource Center. These penalties may be in addition to penalties imposed by the court for any other offense of which you are found guilty.
7. You have no legal right to have an attorney, physician or anyone else present for the purpose of taking the breath samples. You have no legal right to refuse to give, or delay giving, samples of your breath. \
8. Any response from you that is ambiguous or conditional, in any respect, to my request that you provide breath samples, will be treated as a refusal to submit to breath testing. Even if you agree to take the test, but then do not follow my instructions, do not properly perform the test, or do not provide sufficient breath samples, I will charge you with refusal to submit to breath testing.
9. I repeat, the law requires you to submit samples of your breath for testing. Will you submit the samples of your breath?
If the arrested person does not respond, or gives any ambiguous or conditional answer short of an unequivocal “yes,” the police officer shall read the following.
Your answer is not acceptable. The law requires that you submit samples of your breath for breath testing. If you do not answer, or answer with anything other than “yes,” I will charge you with refusal. Now, I ask you again, will you submit to breath testing?