New York Codes, Rules and Regulations › Title 22 - JUDICIARY › Subtitle D - Forms › Chapter VI - Forms For Use In Courts Exercising Criminal Jurisdiction › Form 6a - Nav. L. chemical tests-affidavit

Current through Register Vol. 46, No. 28, July 10,
				2024
Sec. 49 Nav. L. Form 6-A
(Nav. L. Chemical
Tests-Affidavit)
3/90
________ Court of ________
County of ________
________ x
In the Matter of the Application of
Indictment/Docket
________, No. ________
[name of applicant]
AFFIDAVIT
for an order to compel
________
[name of arrestee]
to submit to a chemical test, pursuant to Nav.
				  L. § 49[FN1]
________ x
STATE OF NEW YORK)
) ss.:
COUNTY OF ________)
________, being duly sworn, deposes and says
				  that:
[name of applicant]
1. I am a [police officer employed by the
				  ____________] [district
[name of police department]
attorney as defined in CPL §1.20(32) ]
				  [peace officer acting pursuant to his or her special duties]. At
__
[time] [a.m.][p.m.] on,
__
[date] 19________, I placed
[name of arrestee] under lawful arrest
				  for
violating subdivision(s) ________ of section
				  49 of the
				  Navigation Law. I make this affidavit in support of an application for an order
				  to compel the arrestee to submit to a chemical test, pursuant to section
				  49 of the
				  Navigation Law.
2. I have reasonable cause to believe the
				  arrestee was the operator of a vessel as defined in section
				  49
				  (4)(a)(3) of the Navigation Law, because
				  ____________
____________.
In the course of such operation a person other
				  than the operator [was killed] [suffered serious physical injury or personal
				  injury as defined in section
				  10.00 of the Penal
				  Law, in that said person (describe nature and extent of injuries)
				  ____________
____________].
3. A breath test administered by a police
				  officer in accordance with section
				  49 of the
				  Navigation Law indicates that alcohol has been consumed by the arrestee.
- OR -
Based on the totality of the following
				  circumstances, there is reasonable cause to believe that the arrestee was
				  operating a vessel in violation of subdivision 4 of section
				  49 of the
				  Navigation Law (describe specific circumstances indicating violation)
				  ____________
____________
____________
____________
____________.
4. After being placed under lawful arrest, the
				  arrestee refused to submit to a chemical test in accordance with the provisions
				  of section
				  49 of the
				  Navigation Law, by (describe circumstances of refusal) ____________
____________
____________.
- OR -
After being placed under lawful arrest, the
				  arrestee is unable to give consent to a chemical test in accordance with
				  section
				  49 of the
				  Navigation Law, because (describe incapacity)
____________
____________
____________.
WHEREFORE, it is respectfully requested that
				  the Court issue an order requiring the arrestee to submit to a chemical test to
				  determine the alcoholic or drug content of his/her blood and directing a person
				  authorized by section
				  49
				  (4)(e)(1) of the Navigation Law to withdraw a
				  blood sample from the arrestee for the purpose of determining the alcoholic or
				  drug content thereof.
______________
Deponent
Sworn to before me this
________ day of ________, 19________.
______________
Notary Public
[FN1] Strike all items not
				  applicable