Client Case Information Sheet

Please take a few minutes and record this information about your DUI arrest while it is fresh in your memory. After I receive this questionnaire, my office will contact you by telephone to schedule an appointment to discuss your matter.

The more complete and accurate the information; the better advice I can give you on your Washington State DUI charge and how to best prepare your DUI defense.

If you prefer to fill out a short questionnaire and receive a call from our office, please submit the following form.

Thank you,

Attorney Mark W. Garka

Today's Date:
First Name:
Middle Name:
Last Name:
Other Last Name:
Date of Birth:
Address:
Address2:
City:
State:
Zip:
Home Phone:	Ok to call this phone? (Choose One) Yes No
Cell Phone:	Ok to call this phone? (Choose One) Yes No
May we text message your cell phone:	(Choose One) Yes No
Work Phone:	Ok to call this phone? (Choose One) Yes No
Best Number to Call:	(Choose One) Home Work Mobile
Fax Number:	Ok to fax here? (Choose One) Yes Call First! No
Email:	Ok to email here? (Choose One) Yes No
Confirm Email:
How did you find me?	(Choose One) www.washington-dui.com www.totalattorneys.com www.dui1.com www.superpages.com www.avvo.com www.craigslist.com www.facebook.com www.dexonline.com Dex Phonebook Verizon Phonebook I am a Former Client Referral
If Referral, from Whom?
Employment Profession & Position
Driver's License #:
Driver's License Expiration Date:
State Where Licensed:
License Valid at time of Arrest?	(Choose One) Yes No
Driver's License Required For Job?	(Choose One) Yes No I will not lose job, but need to get to work/school
Do you have a Commercial Driver's License?	(Choose One) Yes No
Do you have a Pilot's License?	(Choose One) Yes No
Do you currently have an attorney?	(Choose One) Yes No
Do you currently have a public defender?	(Choose One) Yes No
Are you a US Citizen?	(Choose One) Yes No
Was anyone in the vehicle 16 years old or younger?	Yes    No
Date of Arrest:
City Where Arrested:
County Where Arrested
Name of Arresting Officer:
Name of Police Department:
Street or Location Where Stopped:
Court Date (if unsure, leave blank):
Is this your first DUI in your lifetime, anywhere, anytime?	(Choose One) Yes No
If you had prior DUI charges, please provide details of Month/Year, Court, Result (Guilty/Not Guilty/Alford):
Are You Currently on Probation or Parole?	(Choose One) Yes No
If Yes, What Court?	(Choose One) Algona Anacortes Arlington Auburn Bellevue Bellingham Black Diamond Blaine Bothell Brier Burien Burlington Carnation Cascade (Arlington) Clyde Hill Concrete Coupeville Covington Darrington Des Moines Duvall East Division (Bellevue, Issaquah, Redmond, Shoreline) Edmonds Enumclaw Everett (Everett) Everett Evergreen (Monroe) Everson-Nooksack Federal Way Ferndale Gold Bar Granite Falls Hunts Point Index Issaquah Kenmore Kent Kirkland LaConner Lake Forest Park Lake Stevens Langely Lynden Lynnwood Maple Valley Marysville Medina Mercer Island Mill Creek Monroe Mount Vernon Mountlake Terrace Mukilteo Newcastle Normandy Park North Bend Oak Harbor Pacific Redmond Renton Sammamish SeaTac Seattle Sedro Woolley Shoreline Skykomish Snohomish Snoqualmie South (Lynnwood) South Division (Burien, Kent, Regional Justice Center) Stanwood Sultan Tukwila West Division (Seattle) Woodinville Woodway Yarrow Point
If Yes, For What Offense?
Other tickets or charges received with this DUI (check all that apply)?	Weaving or Unsafe Lane Changes Speeding Driving on Suspended License License not in Possession Open Container Illegal U-turn Running red light Defective equipment No proof of insurance Failure to Yield Other
Please specify any other charges not listed above:
Why were you stopped-arrested, according to the officer?
Was there an Accident?	(Choose One) Yes No Not Sure
Was anyone injured? (check all that apply)	No one was hurt/not applicable Myself Passenger(s) in my vehicle Passenger(s) in another vehicle Pedestrian Not sure
Were you given field sobriety tests at the location where you were stopped?	(Choose One) Yes No Refused Don't Recall
Which field sobriety tests were you given? (check all that apply):	Handheld Breath Test Result: Follow Pen with eyes Walk and turn 9 steps heel to toe Say the Alphabet One leg stand Touch your nose Other - Please Specify:
Did the officer advise you that tests were 100% optional and that no penalty would result from not doing them?	(Choose One) Yes No
Did you take the breath test?	(Choose One) Yes No, I Refused No, the Test was not offered to me No, I was given a blood test Not Sure
If you took a breath test, you should have a print-out of the two test samples. List your results here:
Sample #1
Sample #2
Name of Testing Officer
Blood Test Results
Were you booked into jail?	(Choose One) Yes No
If yes, number of hours in jail:
Were there any witnesses who can testify for you?	(Choose One) Yes No
If so, who?
What would they add to your case?
If you took a breath test, at any time did you ever ask for or inquire about getting your own independent blood test?	(Choose One) Yes No
Did you ever get your own independent blood test?	(Choose One) Yes No
If yes, what was the result?
Did you ever ask to call an attorney?	(Choose One) Yes No
If yes, when? (give details)
What effect will a conviction have on you personally?
Will a conviction effect your employment? How?
Explain anything else you want me to know about your case:
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