First Name   M.I.   Last Name
Address 1
Address 2
City   State    ZIP Code
Home Phone #      May we call you at this number?  Yes    No
Work Phone #      May we call you at this number?  Yes    No
Cell Phone #      May we call you at this number?  Yes    No
Preferred phone # for call about initial consultation
Best time to reach you at this #
Pager #
Fax #    May we fax you at this number? Yes    No
E-Mail address    May we e-mail you at this address? Yes    No

Date of Birth           State in which you hold driver’s license

Name of Court (on summons, complaint, or bail receipt.)

Court Date (on summons, complaint, or bail receipt.)

Date of Alleged DWI Offense     Time of Alleged DWI Offense

Location of Alleged DWI/DUI offense (Street or highway)

Name of Arresting Officer         Police Department

Why were you stopped, according to Officer?

Were any other charges brought against you arising out of this incident (Would be shown on your summons, complaint, or bail receipt)?

YES    NO    NOT SURE

Was there an accident? YES    NO    NOT SURE

Did you perform roadside sobriety tests? YES    NO    NOT SURE

      Walk and turn (heel to toe) YES    NO    NOT SURE

      Stand on one leg YES    NO    NOT SURE

      Follow pen with eyes YES    NO    NOT SURE

      Say the alphabet YES    NO    NOT SURE

      Touch your finger to your nose YES    NO    NOT SURE

Portable breath test machine YES    NO    NOT SURE     Readout %

Were you given a written or printed report of the result Readout? YES    NO

Were you videotaped? YES    NO    NOT SURE

      By Camera on police cruiser YES    NO    NOT SURE

      By Camera at police station YES    NO    NOT SURE

Did you take a breath test? YES    NO    NOT SURE

       Results shown on printout    Subject #1    %    Sample#2    %         Reported value   %

WARNING If you either refused a test or submitted to a test showing at or above the legal limit of .08% (.02%, if you are under 21, and .04%, if you were driving a commercial vehicle), you face an automatic suspension of your license or right to operate in New Hampshire for at least 180 days and for up to two years. Although you have a right to a hearing, a proper written request for such a hearing must be filed with the department of safety within 30 days. The rules for such filings are technical. Please call right away in order to preserve your right to such a hearing or if you have any questions about your rights or the legal limit that applies to you.

Did you take a blood test? YES    NO    NOT SURE

Have you received blood test results? YES    NO    NOT SURE    Result %

Did you refuse to take a test? YES    NO    NOT SURE

Were you given a temporary license? (Pink 8 ½ x 11 form with six-digit number in upper right-hand corner and filled out by officer)
 YES    NO    NOT SURE

If yes, date notice served (upper right-hand corner)

If yes, name of law enforcement officer shown on bottom section of temporary license entitled, "OFFICER’S REPORT."

Have you gotten a CONFIRMATION OF A NOTICE OF SUSPENSION/ REVOCATION ACTION from the NH Department of Safety?
 YES    NO    NOT SURE

WARNING If you have been previously convicted of dwi/dui within the last seven years in any state, you face a mandatory jail sentence in New Hampshire if convicted.

Is this your first DWI/DUI arrest? YES    NO    NOT SURE

Have you ever been convicted of DWI or DUI? YES    NO    NOT SURE

Please list any previous DWI convictions

1. State    Month    Year    Court

2. State    Month    Year    Court

3. State    Month    Year    Court

4. State    Month    Year    Court

Have you ever lost your license for

Refusal to submit to a chemical test? YES    NO    NOT SURE

State    Month    Year    

Testing above the legal limit? YES    NO    NOT SURE

State    Month    Year    

If you have access to a fax machine, kindly fax your temporary license, any complaints, summons, bail receipt, printout or letter reporting any chemical test result, and Motor Vehicle Department Notice to Struckhoff Law Office at 603-448-2843 or 448-2957.

If you prefer, you may also complete and print the questionnaire and fax it instead of submitting via the Internet. Follow this link to the printable questionnaire.