Declaration and Acknowledgment of Refusal - Breath/Blood Test (Form DC-233)

DECLARATION AND ACKNOWLEDGMENT OF REFUSAL — BREATH/BLOOD TEST
(MOTOR VEHICLES GENERALLY)
Commonwealth of Virginia                                  Va. Code § 18.2-268.3


                                                                INFORMATION ABOUT CONSEQUENCES OF REFUSAL
         The Code of Virginia provides that if you, whether licensed by Virginia or not, operate a motor vehicle upon a
highway in the Commonwealth and are arrested for a drug or alcohol-related driving offense in violation of §§ 18.2-
51.4, 18.2-266, 18.2-266.1 or 18.2-272 (B) or of a similar ordinance, if arrested within three hours of the alleged
offense, you shall be deemed to have agreed, as a condition of such operation, to consent to have a sample of breath,
blood, or both breath and blood taken for chemical testing to determine the alcohol and/or drug content of your blood.
You shall submit to a breath test. If the breath test is unavailable or you are physically unable to submit to the breath
test, a blood test shall be given. If the arresting officer has reasonable cause to believe that you were driving under the
influence of drugs or a combination of drugs and alcohol, you may be required to allow the taking of a blood sample for
chemical testing to determine the drug content of your blood, even if a breath sample was previously provided.
         If you refuse to permit the taking of a required sample of breath, blood, or both breath and blood, and your
refusal is unreasonable, your refusal constitutes a separate offense. A first offense of refusal to permit the taking of
breath, blood, or both breath and blood samples is a civil offense.
         A finding of a first offense of unreasonable refusal will result in the revocation of your privilege of operating a
motor vehicle upon the highways of the Commonwealth for a period of one year. This suspension period is in addition
to the suspension period provided under § 46.2-391.2.
         Subsequent violations of unreasonable refusal to permit the taking of breath samples may be criminal offenses.
A conviction of unreasonable refusal to permit the taking of breath samples within 10 years of you being found guilty
previously of driving while intoxicated or unreasonable refusal will result in finding you guilty of a Class 1
misdemeanor, which is punishable by confinement in jail for not more than 12 months and a fine of not more than
$2,500, either or both, and will also result in the court suspending your privilege to drive for a period of 3 years.
         Subsequent violations of unreasonable refusal to permit the taking of blood samples within 10 years of you
being found guilty previously of driving while intoxicated or unreasonable refusal will result in the revocation of your
privilege of operating a motor vehicle upon the highways of the Commonwealth for a period of 3 years.
         If it is found that you unreasonably refused to consent to a breath test or blood test, that finding may be admitted
as evidence in a criminal trial for a violation of §§ 18.2-51.4, 18.2-266, 18.2-266.1 or 18.2-272 (B) or similar ordinance
for the purpose of explaining the absence at trial of a chemical test of such sample or for the purpose of rebuttal. When
admitted in a criminal trial for a violation of §§ 18.2-51.4, 18.2-266, 18.2-266.1 or 18.2-272 (B) or similar ordinance
this evidence will not be considered as evidence of your guilt.

                                             DECLARATION AND ACKNOWLEDGMENT OF ARRESTING OFFICER

                I, ................................................................................................................................... , an arresting officer in the City/County/Town of
                                                                                  NAME

................................................................................................................................... , Virginia, do hereby certify that I have read this form to


........................................................................................................................................................................... , who has been arrested pursuant to Virginia
                                                                     PERSON ARRESTED
Code §§ 18.2-51.4, 18.2-266, 18.2-266.1, or 18.2-272 (B), or a similar ordinance, and who, after having this form read
to him has refused to permit the taking of a [ ] breath sample and/or [ ] blood sample.

[ ] The person arrested has been convicted of .................................................... violation(s) of §§ 18.2-266, 18.2-268.3, or any
                                                                                              NUMBER OF CONVICTIONS
       offense described in 18.2-270 (E) within the last 10 years.

...........................................................................................                     ___________________________________________________________
                                        DATE                                                                                           SIGNATURE OF ARRESTING OFFICER


                The arresting officer acknowledged under oath before me that he or she had read this form to the person named
                above.

...........................................................................................                     ___________________________________________________________
                                        DATE                                                                                                          MAGISTRATE


FORM DC-233 REVISED 03/17