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Helmet ~ Infraction Stop Report Form - Goes to Sam Hochberg, A.I. M. Attorney

For use if you live in Oregon - Washington - Idaho - Alaska - Hawaii - California

This information may be presented to state and federal legislators as well as police or DOT administrators. The purpose is to ensure appropriate lawmaking and reasonable enforcement. Please provide as much detail as possible. If you have questions please call 1-800-347-1106 or 503-224-1106 in Portland, and ask for Gunny Hutch. Thank you for your cooperation.

~ E-Mail Sam Hochberg ~ Web Site ~

Personal Data

Your E-Mail Address: Your Name:

Day Time Telephone: Evening Telephone:

Address, City, State & Zip:

May we use your name for legislative purposes?

What Happened When You Were Stopped?

When were you stopped? Time: am     pm

Location - where were you stopped?

Officers Name: ID#: Police Agency:

Primary reason for stop: Helmet/Other, please specify:

Cite #: 1st Appearance Date: Time: am      pm

Court Location - City/County:

List any other charges issued at the same time:

If there were any criminal charges (not infractions) issued, Specify:

If you were charged with a crime you should IMMEDIATELY obtain LEGAL ADVICE!

Did the officer follow normal traffic laws in making the stop?
If you do not think the officer followed normal traffic laws please explain:

Did officer treat you fairly and respectfully?
If no, please explain:

Was your helmet confiscated/taken?
If yes, please explain:

Were you given an explanation on legal or illegal helmets?
If yes was the explanation written, verbal or both?
If verbal, describe the explanation:

What Happened In Court?

Have you gone to court?
If you have NOT gone to court, when is court date?

If you HAVE GONE to court, how did you plead?

If you pled GUILTY what was the fine?

If you pled NOT GUILTY, have you gone to trial?

If you pled not guilty and have not gone to trial, when is your court date?

If you have gone to trial, what was the verdict?

If you were found guilty, what was the sentence?


Assessment: State      County      City

Work Time Hours Lost:      Lost Wages:

Briefly describe the evidence you presented at your trial (or mail a copy):

Describe the Helmet You Were Wearing

Brand: Model:

When you bought the helmet did it have a DOT sticker on the outside?

Was the label permanenetly fastened inside the helmet?

Was the helmet modified?

If it was modified please describe the modifications:

Additional Information:


Revision date: 3/1/2006