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CHEMICAL TESTING WARNINGS AND REPORT OF
REFUSAL TO SUBMIT TO CHEMICAL TESTING AS
AUTHORIZED BY ~ OF THE VEHICLE CODE
NAME
SEX
DATE OF BIRTH
MONTH
of'
STATE
F1RSf4lKr+-
ADDRESS
MICDLE
!IJ
G:,-dOhc
/11
CITY
9'; G,
541
M.
STATE
)/</,/11;' I Ie
CHEM TEST REQUEST DATE
MONTH YEAR
0'[ 00
fA
17J.L/ J
DRIVER NUMBER
SOCIAL SECllRITY NUMBER
13 ;2 /5
j' )LJ
fA
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, - ,SECTlON-1547-CHEMICALTESTINGWARNINGS'
1. Ple3so be advised that you are now under arrest for driving under the influence of alcohol or a controlled substance pursuant to section 3731 of
the Vehicle Code. I I '
2. I am requesting that you submit to a chemical test of f3 p(;() (breath. blood or urine. Officer chooses the chemical test.)
3. It is my duty, as a police cffiosr, to inform you that if you refuso to submit to the chemical tast your operating privilege will be suspended for a
period of one year. .
4. a) The constitutional rights you have as a criminal defendant, commonly known as the Miranda Rights, including the right to speak with a laW)/9r and
the right to ramain silent, apply only to criminal prosecutions and do not apply to the chemical testing procedure under Pennsylvania's Implied
Consent Law, which is a civil, not a criminal proceeding. .
b} You have no right to speak to a lawyer, or anyone else, before taking the chemical test requested by the police officer nordo you have a right to
remain silent when asked by the police officer to submit to the chemical test. Unless you agree to submit to the test requested by the police officer
your conduct will be deemed to be refusal and your operating privilege will be suspended for one year.
c-) Your refusal to submit to chemical tasting under the Implied Consent law may be introduced into evidence in a criminal prosecution for driving
while under the influence of alcohol or a controlled substance.
I certify that f have read the above waming to the
nity to submit to chemical testing.
Signature of Office
otorist regarding the suspension of their operating privilege :;&.d gave the motorist an opportu-
Date: I ~CJ
I
I have been advised of the above.
Signature of Motorist:
Date:
Motorist refused to sign, .after being adv~ised. fl' ......, 17- .1/ {J
Signature of Off ---'-----c ~ Date: / /:; '( ~
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1. The above motorist was placed under a~~~fu8~m:lue~1?~alcohol or a controlled substance in violation of Section 3731 of the
Vehicle Code, and there were reasonable grounds to beHeve that the above motorist had been driving, operating or in actual physi~1 control of
the movement of a motor vehicle while under the influenc9 of alcohol or a controlled substance or both. '
or
That the above named motorist was involved in an accident in which the operator or passenger of any vehicle involved or a pedestrian required
treatment at a medical facility or was killed.
2. The above motorist was requested to submit to chemical tasting as authorized by Section 1547 of the Vehicle Coda.
3. The abov9 motorist was informed by a police officer of the chamical test warnings contained in paragraph 3 and 4 above.
4. The above named motorist refused to submit to chemical testing.
OFRCER NOTE- The refusaJlto sign this form is not a refusal to submit to the chemical test. You must still give the motorist an opportu-
nity to take the chemical test after reviewing this form. If the individual was operating a commercial motor vehicle white having any
alcohol or a controlled substance in their system, you must also complete the reverse si of this form.
Officer Signature:
Officer Name:
Commonwealth's
EXHIBIT
I
DAy,31 YEAR 00
JAY (1'),
(Type or Print)
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Forward to:
Department of Transportation
Bureau of Driver Licensing
P.O. Box 60037
Harrisburg,PA 17106-0037
,_T.HlS FOaM MA Y BE DUPLl_C;~I.Iii.D
Badge Number. :J.{... 10 Jurisdiction: !J,p:r/J (IItOO<C[QlI rwf
Phone: r::J.C1.:J ;).l{3-1"f10
Mailing Address #"/2.1'11 (fb.DPLE-roAl 7ipp. Poau D1:f'i.
.
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GIJfU.1:..,Lli' PA, /70/3
Note: Any pertinent facts not covered by the affidavit should be submitted on a
separate sheet and attached hereto. That sheat should include the names of
additional witnesses necessary to prove the elements to which you have attested.
. ADDJTIONA~.S~P~LlES OF THIS FORM MAV BE SECt!REO BY COMPLETING FORM OS-5.11 A
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ROBERT W. GORDON,
Appellant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTYr,'PENNSYL VANIA
v.
CIVIL ACTION - LAW
COMMONWEALTH OF
PENNSYL VANIA,
DEPARTMENT OF
TRANSPORTATION,
BUREAU OF MOTOR
VEHICLES,
Appellee
NO. 00-6269 CIVIL TERM
ORDER OF COURT
AND NOW, this 21st day of September, 2000, upon consideration of Appellant's
Affidavit in Support of Petition for Leave To Proceed in Forma Pauperis, the filing fee is
waived with respect to Appellant's appeal from license suspension.
BY THE COURT,
1
Paul B. Orr, Esq.
50 East High Street
Carlisle, PA 17013
Attorney for Appellant
George Kabusk, Esq.
Office of Chief Counsel
Department of Transportation
3rd Floor, Riverfront Office Center
1101 South Front Street
Harrisburg, PA 17104-2516
Attorney for Appellee
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00 SEP 21 PI1 I: 58
CUMBERlh"JD COUN1Y
PENNSYLVANIA
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ROBERT W GORDON,
Appellant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
v
COMMONWEALTH OF
PENNSYLVANIA, DEPARTMENT:
OF TRANSPORTATION, BUREAU:
OF MOTOR VEHICLES,
Appellee
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NO. 00 -~ CIVIL TERM
PRAECIPE TO PROCEED IN FORMA PAUPERIS
To the Prothonotary:
Kindly allow, Robert W Gordon, defendant, to proceed in forma pauperis.
I, Paul Bradford Orr, attorney for the party proceeding in forma pauperis, certify that I believe the
party is unable to pay the costs and that I am providing free legal services to the party. The party's affidavit
""'wing ""hilily to P'Y the ,~" of li...tion~:9" herein.
at
Paul Bradford Orr, Esq.
Attorney for Robert W Gordon
50 East High Street
Carlisle PA 17013
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ROBERT W GORDON,
Appellant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
v
COMMONWEALTH OF
PENNSYLVANIA, DEPARTMENT:
OF TRANSPORTATION, BUREAU:
OF MOTOR VEHICLES,
Appellee
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NO. 00 _14 CIVIL TERM
AFFIDAVIT IN SUPPORT OF PETITION
FOR LEAVE TO PROCEED IN FORMA PAUPERIS
1. I, Robert W Gordon, am the Appellant in the above matter and because of my financial condition
am unable to pay the fees and costs of prosecuting, defending, or appealing the action or proceeding.
2. I am unable to obtain funds from anyone, including my family and associates, to pay the costs of
litigation.
3. I represent that the information below relating to my ability to pay the fees and costs is true and
correct.
(a) Name: Robert W Gordon
Address: 426 Shivvensburg Road. Newville PA 17241
(b) Social Security Number: 174-38-1129
If you are presently employed, state
Employer: N/A
Address:
Salary or wages per month:
Type of work:
If you are presently unemployed, state
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Date of last employment: 1997
Salary or wages per month: $ 520.
Type of work: Assemblv Line
(c) Other income within the past twelve months
Business or profession:
Other self-employment:
Interest:
Dividends:
Pension and annuities:
Social Security benefits: $ 145. SSI
Support payments:
Disability payments:
Unemployment compensation and
supplemental benefits:
Workman's compensation:
Public Assistance:
Other: $ 85.00 Food Stamps
(d) Other contributions to household support
(Wife)(Husband) Name: Patricia Sue Gordon
If your (husband) (wife) is employed, state
Employer:
Salary or wages per month:
$ 696.00 SSI and Social Security
Type of work:
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ContTibutions from children:
(e) Property owned
Cash: $ 3.00
Checking Account: $ 150.00
Savings Account:
Certificates of Deposit:
Real Estate (including home): $ 21.000. Land and Mobil Home
Motor vehicle: Make Chevrolet Blazer Year 1990
Cost $ 3009.00
Amount owed
Stocks; bonds:
Other:
(f) Debts and obligations
Mortgage: $ 325.00
Rent: N/A
Loans: $ 125.00
Monthly Expenses: Electricity $70./mo: Prooane Gas $7./mo: Homeowner's Ins $23./mo:
Prooertv Taxes $23./mo: Groceries $265./mo: Life Ins $27./mo: Vehicle Ins $33./mo: Vehicle
License/Insoection $ 4.35/mo: Gasoline. Oil, Tires $ 180./mo.Prescription Co-Pay $24./mo
(g) Persons dependent upon you for support
(Wife) (Husband) Name: Patricia Sue Gordon. wife
Children, if any:
Name:
Age:
4. I understand that I have a continuing obligation to inform the court of improvement in my
financial circumstances which would permit me to pay the costs incurred herein.
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5. I verifY that the statements made in this affidavit are true and correct. I understand that false
statements herein are made subject to the penalties of 18 Pa. C.S. 4904, relating to unsworn falsification to
authorities.
Date: ~J:lcJ""Q
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Robert W Gordon, Appell t
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COMMONWEALTH OF PENNSYLVANIA: IN THE COURT OF COMMON PLEAS OF
DEPARTMENT OF TRANSPORTATION, : CUMBERLAND COUNTY, PENNSYLVANIA
Respondent : CIVIL DMSION
v.
: STATUTORY APPEALS
: No. 5!:It Ou - 1...1..1,(1 ~ T~
ROBERT W. GORDON,
Petitioner
ORDER OF COURT
AND NOW, this 2-D t\:; day of ~ rt ' ' 2000, upon consideration of this
APPEAL FROM SUSPENSION OF OPERATOR'S LICENSE, it is hereby ORDERED and
DECREED that a hearing be held on the 7-tJ.; day of ,,(b./'A~, 2000 at
;: 3lJ o'clock -t-m. in Courtroom No. /
of the Cumberland County Courthouse.
A Supersedeas is granted pursuant to Vehicle Code Section 1550 (b) (1) until such time
that this Honorable Court resolves this appeal.
BY THE COURT:
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Distribution:
Pennsylvania Department of Transportation; Office of Chief Counsel;
3rd Floor, Riverfront Office Center; Harrisburg, Pennsylvania 171 04-2516
The Law Offices of Paul Bradford Orr, 50 East High Street, Carlisle, PA 17013)
Paul Bradford Orr, Esquire
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OF '!:" C fJ,C)OTHON07ARY
00 SEP 20 ri'l 2: 54
CUMBEHUvvD COUNIY
PENNSYLVANIA.
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COMMONWEALTH OF PENNSYL VANIA : IN THE COURT OF COMMON PLEAS OF
DEPARTMENT OF TRANSPORTATION, : CUMBERLAND COUNTY, PENNSYL VANIA
Respondent : CIVIL DMSION
v.
: STATUTORY APPEALS
: No.G. (tv - (,,;Jl, q c:.u...a I..v-
ROBERT W. GORDON
Petitioner.
PE'fffiON FOR APPEAL FROM ORDER OF DEPARTMENT
OF TRANSPORTATION SUSPENDING OPERATOR'S LICENSE
TO THE HONORABLE ruDGES OF SAID COURT:
1. Your Petitioner, Robert W. Gordon, is an individual residing at 426
Shippensburg Road, Newville, Pennsylvania, Cumberland County, Pennsylvania 17241.
2. On or about August 21,2000, Petitioner allegedly received a Notice from the
Pennsylvania Department of Transportation notifYing him that his present operator's license,
bearing card number 13215824, was being suspended for a period of one year effective
September 20, 2000. A true and correct copy of said notice is attached hereto, made a part
hereof and marked as Exhibit "A."
3. Said suspension arises out of the Petitioner's alleged chemical test refusal
occurring on July 24,2000.
4. The Notice of Suspension dated August 16,2000, is insufficient as a matter oflaw
and violates due process under the Pennsylvania and the United States Constitutions.
5. Said suspension is not supported by evidence and is erroneous as a matter oflaw.
6. Said suspension is unconstitutional in that it violates due process and equal
protection under both the Pennsylvania and the United States Constitutions.
7. Said suspension is contrary to law in that the officer was without any reasonable
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grounds to believe that the Petitioner was either under the influence of alcohol or a controlled
substance or was involved in an accident in which the Petitioner was the operator or passenger of
any vehicle involved or a pedestrian requiring medical treatment or any resulting fatality.
8. Said suspension is also contrary to established case law in that the warning given
to Petitioner that his refusal to submit to a chemical test might result in license suspension was
insufficient inasmuch as Petitioner was suffering from a mental disorder that preventing him from
comprehending the alleged warning.
9. Said suspension should be automatically stayed upon the filing of this petition and
upon timely notice to the Department of Transportation.
WHEREFORE, your Petitioner respectfully requests that this appeal be granted and, in
the interim, that this Honorable Court enter a stay of Petitioner' s operating privileges pending this
appeal.
Respectfully Submitted,
~o
DATE
Paul Bradfor 0 , Esquire
Attorney for Petitioner
The Law Offices of Paul Bradford Orr
50 East High Street
Carlisle, P A 17013
(717) 258-8558
Supreme Court LD. # 71786
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ROBEHT III GORDON
~2b $HIPP[HSBUHG H)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF TRANS~ORTATION
Bureau of Driver Lieensini
HarriSburg. PA 171Z3
AUGUST 16, ZDOU
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NtWVULE: PA
~724J.
D'~I' HOtor1sL i
As a l"uult of lIaur violetion of Section 1541 01' the
Vehicle Code J CHEMICAL TEST REFUSAL on 07124/2000, your
drivin" llrhiltgt is being SUSPENDED far a "eriod of 1
YEARCS).
In order to complll with this .anction ~ou ar. required to
return any curr'nt driver's license, learner's permit and/or
t'mpDrary driver's lie.nse Ccamara card) in your llassasslon
nD lahr than tll. affective date lhhd. If YDU cannDt
comply with the requirements stated abDv" IIDU are required
to submit a DL16LC Farm or a eworn affidavit stetin. that
YOU ara aware of the .anction e"ainst IIDUr driv:lnlll prlv:l'-
leg.. Failure to comllly with thil notica shall reSUlt In
thiS Bureau referr1ng thl. mittel' to the Pennsylvania State
Po11cel'or Ilroucution under SECTION 1571Ca' (4) of tll. Ve-
hicle COde. .
Alt/loulh the la", mandlltu that lIour clr1v1na privilege is
und.r luap.nsiDn aven if YOU do not lurrender ~our 11~enae.
t!:JI\.,j!l.4! .....'1 ,u.+: h..o"'" 1.1-....1 ..lJ, Q.Uf:\f'1.M.t "1:","...".. li.ILIU
produetCs'. the DL16LC Farm. Dr a letter Ic~nowled.inl YOUr
san~tion is raeaived in tllis Dur.eu.
WHEN THE DEPART"ENT RECEIVES YOUR LICENSE OR ACKNOWLEDgE-
MENT. WE WILL SEND YOU A RECEJPT. IF YOU DO HOT RECEIVE THIS
REC~IPT WITHIN 15 DAVS CONTACT THE DEPARTMENT IMMEDIATELy.
OTHiRWISE, YOU WILL NOT BE GIVEN CREDIT TOWARD SERVING THIS
SANCTION.
Th. .ff..tivI d.t. Df .u...n.lDn it 09/20'2000. 12101 I.m.
_.aa_..a.........._.................................................
IWARNIN~I If ~ou are cDnvicted for driving willIe ~DUr llcen'. il I
Isu,pended. the penaltie. will bel not lal$ thin 90 days lmprison-I
Iment and _ 1,000 fine and In additional 1 year ,uIpanaion. I
......................................................I.............
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, FILE No.576 08/31 '0012:48 ID:LEGAL SERVICES. INC.
FAX: 7172438026
PAGE, 4
, 002226117155080
---....
Ple.s. Sl. the Inelaled epPlic8tion for restoration fll In-
fllr.8thn.
APP'Ala..
V'1l h.ve the r1eht to appnl thh action to the COllrt of
COlllllan Ph... (Chit Dhislon) within 3D dl"" of th'e mull
d,te of this litter, AUGUST 16. 20UO. %~ VOu fill .n .p~..l
in the county co~~t, tn. Caurt will ,iv. vou . tim.-.t.m~.d
o.~ti.,iecl. CtDp)f J!f_ 'the I~JL"~', St,ndth.1.L tiIU-Jlh"ft." "'.p_
'tifled copy of the IPP'11 by clrtified lIIal1 to.
PINN'Y~VANIA DePARTMINT OF TRANIPORTATZON
OPFZCI OP CHIIF COUNIIL
THIRD PLOOR; RZYIR'RONT OFPICe CINTeR
HARRISBURG, PA. 17104-2116
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R,blccl L. BickllY, Director
Bure,u of DrIvlr L1canlin,
SEND FEE/LICENSe/DL-l'LC/TDI
Dlpartmlnt Of fran'Dart8tion
Bur..u af Driver Llcenllnl
P.O. Box 6869&
Werrlsburl, PA 171D6-8693
INFORMATION (7100
IN STATE
OUT-OF-STA TE
TOO IN STATE
TOO OUT-OF-STATE
AM TO 9100 Pill
l-1IID0-9lIZ.4600
717-191.619D
1.80D-228-0676
717-391-6191
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VERIFICATION
I, the undersigned, verifY that the statements made in the foregoing PETITION FOR
APPEAL FROM ORDER OF SECRETARY OF TRANSPORTATION SUSPENDING
OPERATOR'S LICENSE are true and correct to the best of my knowledge, information and
belief.
I understand that false statements made herein are subject to the penalties of 18 Pa. C. S.
Section 4904 relating to unsworn falsification to authorities.
DATE: r~cJ<"Q
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obert W. Gordon, Petiti er
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CERTIFICATE OF SERVICE
I hereby certify that a true and correct certified copy of Petitioner's PETITION FOR
APPEAL FROM ORDER OF SECRETARY OF TRANSPORTATION SUSPENDING
OPERATOR'S LICENSE was served via first class CERTIFIED mail upon the following:
DATE: ~ 11~/oO
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ROBERT W. GORDON,
Appellant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
v.
00-6269 CIVIL TERM
COMMONWEALTH OF PENNSYLVANIA, :
DEPARTMENT OF TRANSPORTATION, :
Appellee
LICENSE SUSPENSION APPEAL
IN RE:
APPEAL DENIED
ORDER OF COURT
AND NOW, this 7th day of December, 2000, upon
consideration of Petitioner's Petition for Appeal from Order of
Department of Transportation, and following a hearing held on
December 7, 2000, the appeal is denied, and the suspension
imposed by notice from Respondent dated August 16, 2000, is
affirmed.
By the Court,
of{
r., J.
J.
George Kabusk, Esquire
Attorney for Appellee
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Paul B. Orr, Esquire
Attorney for Appellant
Sheriff
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