Mail Drop 504M Records Unit Motor Vehicle Division PO Box 2100 Phoenix AZ 85001-2100 MOTOR VEHICLE RECORD REQUEST www.azdot.gov 46-4416 R06/09 Must be signed and notarized on the back At least one permissible use must be checked on the back, unless you are requesting your own record See required fees below The manner in which the Motor Vehicle Division (MVD) may release information from its driver license or motor vehicle records is regulated by the Federal Driver’s Privacy Protection Act (or DPPA), 18 U.S.C. 2721-2725 and Title 28, Chapter 2, Article 5 of the Arizona Revised Statutes. It is the responsibility of the individual or entity making a request to gain knowledge of all federal and state laws which govern access to and use of MVD records, and to determine eligibility under these laws. Anyone who knowingly obtains, discloses, or uses personal information from an MVD record for a use not permitted under these statutes, and anyone requesting the disclosure of personal information who misrepresents their identity or makes a false statement in connection thereto with the intent to obtain such information in a manner not authorized by law, is subject to civil and/or criminal penalties. Requester Information — proof of identification required Requester Name (first, middle, last, suffix) Driver License Number or Other ID Daytime Phone Number ( ) Mailing Address City State Zip Representing (name of business or other organization) Driver Record Type Vehicle Record Type Uncertified 39-Month Certified 5-year Uncertified Certified Other Records Lienholder TSS Assignment Notice Certified Driver Packet (government use only)–Violation Date: Criteria – At a minimum, one Primary Criteria is required (unless Permissible Use #11 is checked). If the criteria you provide below results in no record or multiple records, then additional criteria will be needed to locate the specific record requested. Providing additional criteria with your initial request may avoid delays in processing, or having to pay for “no record found”. Driver Record – Primary Criteria Licensee Full Name (first, middle name or initial, last, suffix) Arizona Driver License/Customer # Has not applied for license License is suspended or revoked Driver Record – Secondary Criteria Licensee Date of Birth (month/day/year) License Expiration Date (month/day/year) Licensee Residence Address City State Zip Vehicle Record – Primary Criteria Arizona License Plate Number Vehicle Identification Number No plate has been issued Owner Full Name (first, middle, last, suffix) Vehicle Record – Secondary Criteria Owner Residence Address City No fee required for government agencies Lienholder Record.....................................$1.50 Record Located Amount Paid Yes Zip Uncertified Fees (per record or document) MVD Use State Check Number Over-the-Counter (while you wait) .....$3.00 Mail-in (must be notarized) ................$3.00 Drop-off .........................................$2.00 Supporting microfilm documents........$3.00 Customer Number Date Paid Certified $5.00 $5.00 $5.00 $5.00 MVD Agent No Comments American LegalNet, Inc. www.FormsWorkFlow.com I am requesting my own record (If this box is checked, a Permissible Uses box does not need to be checked below). Permissible Uses – I understand that the DPPA, as adopted in Arizona law, requires me to have a permissible use for requesting and receiving an MVD record that contains personal identifying information (e.g., a pe rson’s driver license photograph/image, driver license number, name, address and medical/disability information). Based on the specific uses checked below, I hereby certify that I am entitled to obtain the re quested record under the authority of ARS Title 28, Chapter 2, Article 5. For use by any government agency, including any court or law enforcement agency, in carrying out its functions or any private p erson or entity acting on behalf of a government agency in carrying out its functions (Permissible Use #1) For use by an attorney licensed to practice law or by a licensed private investigator in connection with any civil, criminal, a dministrative or arbitration proceeding in any court or government agency or before any self-regulatory body, including the service of process, investigation in anticipation of litigation and the execution or enforcement of judgments and orders, or pursuant to a court order Professional License Number Court Name and Case Number (if available) (Permissible Use #4) For use by any insurer that writes automobile liability or motor vehicle liability policies and that is under the jurisdiction of the department of insurance or insurance support organization or by a self-insured entity or its agents, employees or contractors in connection w ith claims investigation activities and antifraud activities, rating or underwriting (Permissible Use #6) For use by an employer or its agent or insurer to obtain or verify information relating to a holder of a commercial driver lice nse that is required under the commercial motor vehicle safety act of 1986 (49 U.S.C. 31301 through 31317) (Permissible Use #9) For any other use in response to requests for individual motor vehicle records if the state has obtained the express consent of the person to whom the personal information pertains (two Primary Criteria and one Secondary required) (Permissible Use #11) For use by any requester if the requester demonstrates he or she has obtained the written consent of the individual to whom the information pertains (signed and notarized Consent to Release Motor Vehicle Record–One-Time, form # 96-0463, must be attached) (Permissible Use #13) Only if a box is checked for one or more of the six permissible uses above, may the requester specifically request the person’s driver license photograph/image or medical/disability information. Photo/Image (select locations only) Uncertified Certified For use in connection with matters of at least one of the following: (a) Performance monitoring of motor vehicles, motor vehicl e parts and dealers (b) Motor vehicle market research activities, including survey research (c) Removal of non-owner records from the original owner re cords of motor vehicle manufacturers (Permissible Use #2) For use in the normal course of business by a legitimate business or its agents, employees or contractors, but only: (a) To ver ify the accuracy of personal information submitted by the individual to the business or its agents, employees or contractors; or (b) If the information submitted is not correct or is no longer correct, to obtain the correct information for the purpose of preventing fraud by, pursuing legal remedies against or re covering on a debt or security interest against the individual Federal Tax Identification/Vendor or Professional License Number Applicable Licensing Agency (Permissible Use #3) For use in research activities and for use in producing statistical reports if the personal information is not published, re-di sclosed or used to contact individuals (Permissible Use #5) For use in providing notice to the owners of towed or impounded vehicles (Permissible Use #7) For use by any licensed private investigative agency or licensed security service, as indicated by an additional permissible use (You must check a second permissible use.) (Permissible Use #8) For use in connection with the operation of private toll transportation facilities (Permissible Use #10) For any other use that is specifically authorized by law and that is related to the operation of a motor vehicle or public safety, including the following (check at least one more of the following): (a) Use by a financial institution or enterprise under the jurisdiction of the Department of Financial Institutions or a federal monetary authority (b) Use by a motor vehicle dealer who is licensed and bonded by the Department or a state organization of licensed and bonded m otor vehicle dealers (c) Use by a person who is involved in an accident or the owner of a vehicle involved in an accident if the person who requests the information submits proof to the Department of involvement in the accident (d) Use by a person applying for a bonded title if all of the following conditions exist: (i) The requester verifies to the satisfaction of the Director that the vehicle on which the requester is requesting the record is in the requester’s possession (ii) The record is requested in order for the requester to notify the registered owner of the requester’s intent to apply to the Department for a bonded title (iii) The requester provides a verification of a vehicle inspection that was performed by an authorized Department employee or agent (e) Use by an operator of a self-service storage facility who alleges both of the following: (i) That the vehicle on which the operator is requesting the record is in the operator’s possession (ii) That the record is requested to allow the operator to notify the registered owner and any lienholders of record of the operator’s intent to foreclose its lien and to sell the vehicle (Permissible Use #14) Certification – I hereby certify, under penalty of perjury, that any records or information obtained pursuant to this request will be used s olely for the uses indicated on this form, and for no other use. I understand that I am prohibited from selling or disclosing the personal informa tion set forth in these records, except in accordance with applicable law. I further acknowledge that MVD, by giving me access to the requested record information, is relying on the truth of the representations contained on this form, and I am intending that MVD so rely. I therefore agree to defend, h old harmless and indemnify MVD and any of its officers, employees, agents or contractors, from all actions brought or damages alleged by reason of the negligent, improper or unauthorized use or dissemination of the information provided to me by MVD. Requester Name (first, middle, last, suffix) Requester Signature Acknowledged before me this date. Date County Notary or MVD Agent Signature State Commission Expires American LegalNet, Inc. www.FormsWorkFlow.com