Florida Department of Highway Safety and Motor Vehicles · Florida state form

BAR1001A Affidavit of Refusal to Submit to Breath Test

BAR1001A is an affidavit for a law enforcement or correctional officer to document a driver’s refusal to submit to a requested breath test.

What this form is

This affidavit records the officer, agency, driver, arrest, citation, and circumstances of a breath-test refusal. It includes the warnings given about possible driving-privilege suspension and commercial driver’s license disqualification. The officer completes and signs the affidavit, which must be notarized or attested to. The form directs the officer to mail or hand deliver it with the driver’s license, appropriate UTC copy, and probable cause affidavit.

Who needs it

A law enforcement or correctional officer uses this affidavit to document a driver’s refusal to submit to a requested breath test.

Why it needs a notary

The affidavit must be notarized or attested to. Notarization can be completed online with a commissioned online notary.

How to submit it

Mail or hand deliver the affidavit to the designated Bureau of Administrative Reviews office with the driver’s license, appropriate copy of the UTC, and probable cause affidavit.