1. (a) An applicant requesting a DWI sign assembly, name plaque, or both, shall provide the following information to the bureau of traffic on or with the “Driving while Impaired Victim Fatality Sign Application” furnished by the bureau of traffic:

   1. (1) The name, address, and telephone number, or other means of contacting the applicant during regular business hours;
   2. (2) The applicant’s relationship with the victim;
   3. (3) The date of the traffic accident;
   4. (4) The location of the traffic accident, including the street and town;
   5. (5) The name of the motor vehicle driver driving while intoxicated or under the influence of drugs;
   6. (6) The name of the individual(s) fatally injured, as it or they should appear on the name plaque(s), and the name of the nearest living relative and their relation to the victim(s);
   7. (7) The name of the investigating police agency;
   8. (8) A certified copy of a conviction for violation of RSA 265-A:2 or RSA 265-A:3 by one of the drivers involved in the fatal accident, to establish that the driver who was at fault for the traffic accident was impaired by drugs or alcohol and that the individual(s) to be memorialized was fatally injured in the traffic accident;
   9. (9) An affidavit by the applicant that the individual(s) to be memorialized was fatally injured in the traffic accident and that there is substantial evidence gathered by law enforcement that the other driver was at fault and that drugs or alcohol were involved; and

   10. (10) The required fee of:

       1. a. $ 250.00 if a DWI sign assembly for the traffic accident does not exist; or
       2. b. $200.00 to add a name plaque to an existing DWI sign assembly for a victim of the same traffic accident.

2. (b) Notwithstanding (a)(8) above, if a certified copy of conviction is not available due to lack of prosecution due to death of the impaired driver or other inability to prosecute unrelated to sufficiency of evidence, then the following documents shall be considered by the department in determining that one of the drivers was at fault and impaired by drugs or alcohol:

   1. (1) Relevant medical records to show the driver in a vehicle collision was impaired by drugs or alcohol;
   2. (2) Investigating officer’s accident report that indicates the driver of one of the vehicles was impaired by drugs or alcohol; or
   3. (3) Other reliable records provided by the applicant indicating one of the drivers was impaired due to drugs or alcohol.

Source. #10165, eff 7-27-12; ss by #13588, eff 3-22-23