REQUEST FOR VIDEO RECORDING OF ARREST To: ________________________ (Name of Arresting Agency) My name is _________________________________. My date of birth is ____________________. My Driver License Number is ___________________________ (DL # and State). On or about _______________ (date) I was arrested for suspicion of: Driving While Intoxicated Driving While Intoxicated Child Passenger Intoxication Assault Intoxication Manslaughter. Pursuant to Code of Criminal Procedure Article 2.139, I am requesting a copy of any video made at by or at the direction of your officers or deputies relating: • the stop; • the arrest; • any interaction I had with officers, including administration of the field sobriety tests, transport to the jail or for a blood draw, and any interaction between representatives or employees of your department and myself; • the blood draw or breath test. Please provide the videos to me: by making it available for pick up. Contact me at __________________________ (Phone number or email address) when the video is available for pick up. by mailing it to me at the following address: ______________________________________________________________________________ This request was made on _______________________ (Date) by: (select one of the following:) Fax to ________________________ (Fax Number) Mail Hand-delivery Other: _____________________________________________ (Specify)

This form was created by the attorneys at Varghese Summersett PLLC and is provided as a courtesy to Texas residents who have been arrested for an offense under Chapter 49 of the Texas Penal Code. For more information visit https://www.versustexas.com/.