Form Center

2. First Name
3. Last Name
5. Date of Birth
   Date of Birth
6. Age
7. Driver's License #
8. State
10. Address
12. City
13. State
14. Zip Code
16. Phone Number
17. Last 4 of SSN
18. US Citizen

    1. Yes
    2. No
20. Date of Arrest
21. Arresting Agency
22. BAC
24. Ethnicity
25. Marital Status
26. Lenawee County Resident?

    1. Yes
    2. No
27. If no, what county:
29. Check which charge applies:

    1. OWI 1st
    2. OWI 2nd
    3. Operate with a High BAC
    4. Seeking
    5. Other
30. If other, specifically what charge:
31. Registered or convicted sex offender?

    1. Yes
    2. No
    3. Unknown
32. Any prior violent crime convictions?

    1. Yes
    2. No
    3. Unknown
34. Was a firearm involved in current charge?

    1. Yes
    2. No
    3. Unknown
35. Does person have or claim to have a medical marijuana card?

    1. Yes
    2. No
    3. Unknown
37. Comments:
39. This form was completed by:
40. Date:
    Date:
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit Submit and Print

* indicates a required field