D.U.I.
If you believe that you or someone close to you may have a DUI matter and may require legal counsel, please fill out the following questionnaire. By submitting the information below, you will enable the attorneys at the Wilbur Smith Law Firm to evaluate your case based on its merits. Please be as complete as possible in the information you provide. If you have a potential case not related to a DUI, please fill out our Personal Injury evaluation form. If you would like to contact the Wilbur Smith Law Firm for reasons other than a possible personal injury claim or a criminal defense matter, please use our General Contact Form.
Your Name: (required)

Street Address:

City:

State:

Zip:
 E-mail Address (required)

Home Phone:

Work Phone:

Fax Number:
Preferred method of contact:
What time of day would you like us to call?

General Incident Information:

Date that the incident occurred (00/00/00): / /

Time of day that the incident occurred:

Where did the incident occur?

Please list all of the charges cited as a result of this incident:


Name of the Arresting Officer:

Branch of Law Enforcement that made the arrest:
City Police Office
County Sheriff's office
State Highway Patrol

Did you perform a field sobriety test?
Yes
No
Not Sure

If Yes to above, what were the results?
Passed
Failed
Not Sure

Did you perform a breathalyzer test?
Yes
No
Not Sure

If yes to above, what was your blood alcohol level?
Time of day breathalyzer test was taken:

Any additional comments about your DUI:
Important Legal Disclaimers:
Yes No - I agree that this matter may be referred to an attorney in my area who may contact me.

Yes No - I agree that the information that I will receive in response to the above question is general information and I will not be charged for the response to this
e-mail question.

Yes - I agree that the above does not constitute a request for legal advice and that I am not forming an attorney client relationship by submitting this question. I understand that I may only retain an attorney by entering into a fee agreement, and that I am not hereby entering into a fee agreement.

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1415 Hendry Street · P.O. Drawer 8 · Fort Myers, Florida 33902-0008
Phone: (239) 334-7696 · Fax: (239) 334-3669 · Email: info@wilburlaw.com
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