THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) ACKNOWLEDGMENT AND WAIVER OF RIGHTS DWI � FIRST OFFENSE- CLASS B MISDEMEANOR I, of have been charged with driving or operating under the influence of drugs or liquor, first offense, a class B misdemeanor. I understand that I have the right to be represented by a lawyer of my own choosing and at my own expense. If I am not a citizen of the United States, I understand that conviction of the crimes(s) for which I intend to plead GUILTY or NO CONTEST may have immigration consequences, including but not limited to, deportation from the United States, exclusion from admission into the United States, or denial of naturalization pursuant to the laws of the United States. I am represented by , a lawyer admitted to practice in New Hampshire. I am satisfied with my lawyer and all explanations have been clear. I do not want a lawyer. I understand and know what I am doing. I hereby waive being represented by a lawyer. I understand that I do not have to plead GUILTY or NO CONTEST and that even after signing this form I still do not have to plead GUILTY or NO CONTEST. I understand that by pleading GUILTY or NO CONTEST to the complaint(s) that I am giving up the following constitutional rights as to the charge(s): MY RIGHT to a speedy and public trial. MY RIGHT to see, hear and question all witnesses. This gives me the opportunity and right to face the witnesses against me and question them myself or through my attorney. MY RIGHT to present evidence and call witnesses in my favor and to testify on my own behalf. MY RIGHT to remain silent and not testify at a trial. MY RIGHT to have the judge ORDER into court all evidence and witnesses in my favor. MY RIGHT not to be convicted unless the State proves that I am guilty beyond a reasonable doubt with respect to all elements of the charge, which have been explained to me. MY RIGHT to keep out evidence, including confessions, illegally obtained. MY RIGHT to appeal to the Supreme Court on issues of law. I GIVE UP ALL THE ABOVE RIGHTS OF MY OWN FREE WILL. I understand that by pleading GUILTY or NO CONTEST I am admitting to or not contesting the truth of the charge(s) against me in the complaint(s) and that upon the judge's acceptance of my GUILTY or NO CONTEST plea, a conviction(s) will be entered against me. No force has been used upon me, nor have any threats been made to me, by any member of the Prosecutor's Office or anyone else to have me enter this plea of GUILTY or NO CONTEST. NHJB-2821-D (01/13/2017) Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: ACKNOWLEDGMENT AND WAIVER OF RIGHTS DWI � FIRST OFFENSE No promises have been made to me by any member of the Prosecutor's Office or anyone else in an effort to have me enter this plea of GUILTY or NO CONTEST to the charge(s), except as follows: I understand as a consequence of my plea of GUILTY or NO CONTEST that the judge may impose such sentence as in his/her discretion s/he considers appropriate. If the judge does not accept the terms of the negotiated plea I may withdraw my plea. I understand that the complaint is one accusing me of DRIVING OR OPERATING UNDER THE INFLUENCE OF DRUGS OR LIQUOR, FIRST OFFENSE, A CLASS B MISDEMEANOR. I understand that upon the judge accepting my plea, the judge shall enter a finding of guilty and the following sentence will be imposed: 1) I shall be fined not less than $500.00 and not more than $1,200.00. 2) My driver's license or privilege to drive shall be revoked for not less than 9 months nor more than 2 years. The court may suspend up to 6 months of this revocation period provided I comply with the following requirements: a.) I shall be referred to an Impaired Driver Care Management Program (IDCMP) and shall be required to submit to an alcohol and drug abuse screening within 14 days of conviction. b.) If the screening demonstrates the likelihood of a substance use disorder, I shall be required to submit to a full substance use disorder evaluation within 30 days of conviction and shall be required to follow the service plan developed from that evaluation. c.) I shall be required to pay all fees arising from services provided by the IDCMP and its referrals for the service plan if applicable. d.) Along with the alcohol and drug abuse screening and/or substance use disorder evaluation, I shall be required to complete an approved Impaired Driver Education Program (IDEP) prior to the restoration of my driver's license or privilege to drive, unless I have completed such a program within the past 5 years. e.) In addition to the foregoing, I understand that the court may also require the installation of an alcohol ignition interlock device in any vehicle driven by me during the period of sentence reduction. I understand that I shall bear the cost of installation and fees associated with the device, and the court may also re-impose the longer license revocation period if I become noncompliant with the treatment recommendations at any time. PENALTIES FOR DWI OFFENSE OCCURING UNDER THE AGE OF 21 3) I shall be fined not less than $500.00 and not more than $1,200.00. 4) My driver's license or privilege to drive shall be revoked for not less than 12 months nor more than 2 years. 5) I shall schedule a substance use disorder evaluation with an Impaired Driver Care Management Program (IDCMP) service provider within 30 days of conviction 6) I shall complete the substance use disorder evaluation within 60 days of conviction and shall be required to follow the service plan developed from that evaluation. 7) I shall be required to pay all fees arising from services provided by the IDCMP and its referrals for the service plan if applicable. 8) Along with the substance use disorder evaluation, I shall be required to complete an approved Impaired Driver Education Program (IDEP) prior to the restoration of my driver's license or privilege to drive, unless I have completed such a program within the past 5 years. NHJB-2821-D (01/13/2017) Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: ACKNOWLEDGMENT AND WAIVER OF RIGHTS DWI � FIRST OFFENSE 9) In addition to the foregoing, I understand that the court may also require, after the period of revocation, the installation of an alcohol ignition interlock device in any vehicle driven by me, until I turn the age of 21 or for not less than 12 months, whichever i