Breath Alcohol Test Affidavit

Breath Alcohol Test Affidavit

Florida Department of Law Enforcement
Alcohol Testing Program
Breath Alcohol Test Affidavit
Instrument Type: Intoxilyzer 8000
Instrument Registered To:
Instrument Serial Number:     Software:
 Date of Test:
  Date of Last Agency Inspection:
  Observation Period Began:
  Subject’s Name:                                             DOB:                 Sex:
The subject was observed for at least twenty-minutes prior to the administration of the breath test to ensure that the subject did not take anything orally and did not regurgitate. 

Results:
State of Florida, County of ____________________,
Personally appeared before me the undersigned authority, who (__) is personally known to me or (__) produced ______________________ as identification, and who after being placed under oath, states:
I                                , hold a valid Breath Test Operator permit issued by the Florida Department of Law Enforcement, I administered the above breath test to the subject named above in accordance with Chapter 11D-8, Florida Administrative Code, and this form is a true and accurate report of that breath test.
Breath Test Operator: _____________________________________________  Date: _____________
                                     Signature
                              
Sworn to (or affirmed) before me this ______ day of ___________________________, ___________
_____________________________________________  _____________________________________________
Signature of Notary Public-State of Florida            Printed Name of Notary Public-State of Florida
Note:  Pursuant to section 117.10, Florida Statutes, law enforcement officers, correctional officers, traffic accident investigation officers and traffic infraction enforcement officers are notaries public when engaged in the performance of official duties.  In accordance with section 316.1934(5), F.S., this completed form is admissible without further authentication and is presumptive proof of the results herein.  To be used in accordance with Section 316.1934(5), F.S., and in administrative proceedings pursuant to 322.2615, F.S.