DWI / DUI Case Evaluation Form

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Below you will find the DWI/DUI Case Evaluation Form. Please complete it to the best of your knowledge and Thomas C. Mooney will contact you ASAP. If you are unsure of some information leave it blank. The information you provide is protected by Attorney-Client privilege. After you finish providing the information click "Submit" and your responses will be sent to Thomas C. Mooney.

Remember you can discuss the same information directly with Thomas C. Mooney over the phone or in person. Call his office at (301) 574-0800. Additionally you have the option of faxing him the print version of this form.

Contact Information
Full Name
Address
City
State
Zip
Primay Phone
Secondary Phone
E-mail
Contact Preference Please include your preference as to how/when/where you'd like to be contacted.
License, Legal and DWI/DUI History
Driver's License Number
State of License
Date of Birth
Are you on probation?	yes     no
If yes, please indicate where
Have you been previously charged with a DWI/DUI?	yes     no
If yes, briefly describe the facts of the case(s). Include the date, location, and outcome.
Dates and Locations of Arrest and Court
Date of Arrest
State of Arrest	(only accepts cases from the state of Maryland)
City of Arrest
County of Arrest
Name of Court
Court Date
Field Sobriety/Blood/Breath Testing Information
Was the field sobriety test administered on location of arrest/stop?	yes     no
If yes, which of the following tests were you given?
Handheld Breath Test	yes     no
Walk-and-turn 9 steps heel to toe	yes     no
One-Leg Stand	yes     no
Follow-the-Pen-With-Eyes	yes     no
Say the Alphabet	yes     no
Touch Your Nose	yes     no
Other test(s) administered for the field sobriety
Medical conditions or injuries that affect your eyesight or balance?
Did you take the breath test?	yes     no
If yes, what were the results of the two sample breath tests?	Result 1     Result 2
Results of the blood test
Did you request your own independent blood, breath, or urine test during the arrest?	yes     no
If yes, what were the results of the independent tests?
Specific Case Information
Reason you were stopped
Did an accident occsur?	yes     no
Did any injuries occur?	yes     no
If yes, include details of who was injured
Were there a witness(es) who could testify for you?	yes     no
Did you request an attorney?	yes     no
Addition comments
How do you presently wish to plead?	guilty     not guilty
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If other, specify