INSTRUCTIONS FOR RECOUPMENT OF FUNDS FORM
(Refer to circled numbers on sample form.)
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Last name, first name, middle initial of person arrested.
Street(or route), city, state, and zip code where arrested
person lives.
Arrested person's date of birth, either numbers(for example,
2-17-60) or with month spelled out(February 7, 1960).
Arrested person's drivers license number(on recent issues, it
will be the same as the social security number).
Title of the arresting agency: Bridgeton Police Department.
Street, city, and zip code of arresting agency - 11955 Natural
Bridge Road, Bridgeton, Missouri 63044
Phone number(s) of the arresting agency: (314) 739-7557.
Full name of the arresting Officer(s).
Rank of the arresting Officer(s).
DSN number of the arresting Officer(s).
Hours and minutes (rounded to the nearest half hour) spent
processing the arrestee.
Arresting agency's cost per hour, per Officer, for processing
the arrestee.
Total processing cost, determined by multiplying hourly rate
times hours and minutes (rounded to the nearest half hour)
spent processing the arrestee.
Cost of operating the breath-testing instrument to test the
arrestee.
Cost of all laboratory tests to determine the alcohol content
of the arrestee, including blood, saliva, and urine tests.
Signature of arresting Officer's Supervisor, verifying that
the above data is correct.
Month, day, and year document was certified.
Total of costs associated with processing breath-testing, and
laboratory testing.
Inclusive dates of arrestee's incarceration, including
month(s), date(s), and year(s).
Total Days arrestee was incarcerated(a fraction of a day
counts as a whole day).
Cost of incarcerating the arrestee for one day.
Total cost of incarceration(multiply days incarcerated times
cost per day).
Signature of person of authority verifying above costs.
Month, day, and year document was certified.
Total of arrest, processing, and incarceration costs.
ENCWSURE #1
REQUEST FOR RECOUPMENT OF FUNDS
Rccoupmcnt of costs itemized below are requested under Section 577 .048, RS Mo., . as the result
of a conviction for violating the provmonsI of Sections 577.010 or 577.012 or v!olaiions 0£,
county or municipal ordinances involving .alcohol . or drug related .traffic offenses·.
(j)Defcndant
@Address - - - - - - - , - - - - - - - - - - - - - - - - - - - - - - @:>OB ____________.,@~4Drivers Lkense # - - - - - - - - - - - - - - - @Address
@Arresting
Officer!s)
@&..W@Badie
<i)fhope
(j)Hours/Mln. . ~Cost
r Hotl(
Processin11
(j))Breathtesting
Instrument
@Laboratory Tests
Based on the information available to me, the above information is true a.nd correct.
@Cenifying Officer
@Date - - - - - - - - - - -
@ .....__ _ __
SUBTOTAL ARREST AND PROCESSING COST
Incarcerating
Agency
{?)Addre.ss
<!J)Dares of Incarceration
Ci]) Days
(!}) Sybtpta!
Incarcerated
Based on the Information available to me, the above infonnation is true ·and correct.
@Cenifylng Officer
Ii]) GRAND
TOTAL
@Date
COST:
Arrest/Process! n g/Inca rcer a ti on
Note:
Coples of the uniform complaint and summons
breathtestlni: results will be attached to this form.
$
along with
the
ENCWSURE #2