Please fill out this online-form. When you are finished, click on the "SUBMIT" - Button at the end.
INFORMATION SUBMITTED TO THIS OFFICE IS PROTECTED BY THE ATTORNEY-CLIENT PRIVILEGE AND WILL NOT BE SHARED WITH ANYONE OUTSIDE OF LOTHSTEIN LAW OFFICE, LLC, WITHOUT YOUR PRIOR PERMISSION.
First Name M.I. Last Name Address 1 Address 2 City State ZIP Code Preferred phone # for call about initial consultation Best time to reach you at this # E-Mail address May we e-mail you at this address? Yes No
Date of Birth State in which you hold driver’s license CDL Yes No
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 (City or Town)
Why were you stopped, according to Officer?
Did you take a breath test? YES NO NOT SURE Results shown on printout: 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
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