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THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) ACKNOWLEDGEMENT OF LICENSE PENALTY (Pursuant to RSA 203:56-b) I was fifteen (15) years or older, but not yet eighteen (18) years old at the time of the offense. I understand that if I am convicted, found to be delinquent (RSA 169-B) or found to be in need of services (RSA 169-D) for any offense involving the sale, possession, use, or abuse of alcohol or of controlled drugs, or of a controlled drug analog, may at the discretion of the court be subject to the revocation or denial of a driver's license. I understand in the case of a denial of an application for a new license, the period imposed shall begin on the date I am eligible by age for the issuance of a license. I am being charged with I further understand: on the first offense, the director shall revoke my driver's license or deny an application for a license for not less than 90 days but not more than one year, and not less than 6 months but not more than 2 years for a subsequent offense, provided the director gives me an opportunity for a hearing: if convicted for the offense of possession with intent to sell a controlled drug or controlled drug analog. I shall be subject to revocation or denial of a driver's license for a mandatory period of at least one year and a maximum period of up to 5 years. (RSA ) Date Juvenile Parent/Guardian I, the undersigned justice, have explained to the above juvenile and parent/guardian and believe that they understand the loss of license penalty which will result from a conviction or finding of this offense. So Ordered: Date Signature of Judge Printed Name of Judge NHJB-2353-DF (12/06/2006) (formerly AOC 319-008/004) Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com