NHJB-2026-DS (12/10/2018) Page 1 of 3 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) PETITION FOR LIMITED DRIVING PRIVILEGES PURSUANT TO RSA 263:57-b. On , I was found guilty of Driving Under the Influence 1st offense and am eligible to be allowed limited driving privileges on (at least 45 days from date of suspension or revocation) I was not driving a commercial vehicle at the time of my offense. I request that the court approve my request for limited driving privileges because (check and complete all that apply): I am required to operate a motor vehicle in connection with my employment. Attached is a copy of a statement from my employer verifying the specific times I need to operate a vehicle in connection with my employment. I request authorization to drive in connection with my employment on the following dates and times: I must operate a motor vehicle to get to my place of employment. My home is located at My employer is , located at Attached is verification of my employment and my specific work hours. I request authorization to drive to and from my work on the following dates and times: I am currently unemployed or seeking to become employed and request authorization to drive to and from job interviews on the following dates and times: I must operate a motor vehicle to get to or from an alcohol or drug treatment or rehabilitation program. Attached is verification of my enrollment in an alcohol or drug treatment or rehabilitation program and the days and specific times I am required to attend. I request authorization to drive to attend this program on the following dates and times: American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: PETITION FOR LIMITED DRIVING PRIVILEGES NHJB-2026-DS (12/10/2018) Page 2 of 3 I must operate a motor vehicle because I, or a person in my immediate family, require medical treatment on a regular basis and I must operate a motor vehicle so that treatment may be obtained. The name of my family member is My family relationship to this person (e.g. husband/wife/son/daughter etc.) is This person lives at and the medical facility where they receive treatment is located at I request authorization to drive this person to medical appointments on the following dates and times: I must operate a motor vehicle to continue my education. Attached is verification of my enrollment in an educational institution and a copy of my class schedule. I request authorization to operate a motor vehicle to continue my education on the following dates and times: I must operate a motor vehicle to attend job training. Attached is verification from my employer of my need to attend job training requiring me to drive a vehicle and the specific times of the training. I request authorization to drive a vehicle to attend job training on the following dates and times: I understand I may not operate a motor vehicle until I have submitted proof of financial responsibility to the Department of Motor Vehicles as required by RSA 265-A:28. I understand that, pursuant to RSA 263:57-b. VI, I will be subject to the ignition interlock program for one year from the date of this order restoring my driving privileges on a limited basis. On pain and penalty of perjury I certify that the above facts are accurate and a copy of this motion has been sent to (prosecutor name) who agrees with this request OR objects to this request. I acknowledge that I am being truthful in making all the above requests. I further acknowledge that I have provided the court with satisfactory evidence in support of this petition and that the documentation submitted by me is honest and accurate. Date Signature Address Printed Name Town, State, Zip Code Date of Birth American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: PETITION FOR LIMITED DRIVING PRIVILEGES NHJB-2026-DS (12/10/2018) Page 3 of 3 ORDER This petition is denied for the following reason(s): This petition is granted on the following conditions: Prior to operating a vehicle you are directed to obtain a physical Limited Privilege License from the Division of Motor Vehicles and submit proof of financial responsibility to the Division of Motor Vehicles in accordance with RSA 265-A:28. This driving privilege will be limited to the times, places, and days determined by the court to be necessary for you to seek or retain employment, to attend any alcohol or drug treatment or rehabilitation program, to continue your education, to attend job training or to obtain required medical treatment for yourself or a member of your immediate family as has been detailed in this petition. This driving privilege shall be limited to vehicles equipped with enhanced technology ignition interlock devices. You shall be subject to the ignition interlock program for one year following the date of this order restoring your driving privilege on a limited basis. This driving privilege is further limited to the following specific times, places, and days: This limited privilege shall not be effective until your license has been suspended or revoked pursuant to criminal penalty or administrative suspension, for at least 45 days, and this limited driving privilege shall expire on . This order does not interrupt or supersede any administrative license suspension imposed by the Department of Safety pursuant to RSA 265-A:30. Any violation of any of the terms or conditions of this limited driving privilege will be deemed a violation of RSA 263:64 and your limited license shall be revoked and you may be charged with a misdemeanor offense of operating after suspension for driving under the influence of drugs or alcohol and if convicted, your license will be revoked for an additional one year and no further limited driving privileges will be granted, and a minimum mandatory jail sentence of 7 days will be imposed. This violation is a major motor vehicle offense under the habitual offender law. You must deliver a copy of this order to the law enforcement agency in the city or town where you live and you must carry a copy of this order on your person or in some easily accessible place in the vehicle you are operating. This Order is not a Provisional License Date Signature of Judge Printed Name of Judge American LegalNet, Inc. www.FormsWorkFlow.com