FINANCIAL RESPONSIBILITY INFORMATION REQUEST A Public Service Agency Mail To: Department of Motor Vehicles -- Financial Responsibility (FR) (916) 657-6677 P.O. Box 942884, Mail Station J237,Sacramento, CA 94284-0884 SECTION 1 -- TYPE OF INFORMATION REQUESTED Insurance Information from File information in NAME Photocopy of SR 1 Report . Please enclose a check or provide your requester code directly under your name and address. Please allow for processing. Explain your interest in this accident: (Required per (CVC) §16005) (Check appropriate box) STATE ZIP CODE SECTION 2 -- REQUESTER'S INFORMATION STREET ADDRESS CITY TELEPHONE NUMBER ( ) Fill out the information below to have your requester account billed. VENDOR AGREEMENT NUMBER Involved as a: Driver/owner Pedestrian Bicyclist Passenger Owner of damaged property Insurance company, representing involved party Attorney for involved party, who is: Vehicle driver/owner Pedestrian Passenger Bicyclist Other: LOCATION (CITY) VENDOR REQUESTER CODE NUMBER VENDOR NAME SECTION 3 -- ACCIDENT-RELATED OR CLIENT INFORMATION DATE OF REQUEST FR FILE NUMBER (IF KNOWN) ACCIDENT DATE YOUR CLIENT OR INSURED NAME OF DRIVER OF VEHICLE YOU OR YOUR CLIENT WAS IN DAMAGE OR INJURY TO Pedestrian DRIVER LICENSE NUMBER BIRTH DATE ADDRESS (REQUIRED) Bicyclist Property Owner SECTION 4 -- SUBJECT OF INQUIRY NAME BIRTH DATE ADDRESS DRIVER LICENSE NUMBER VEHICLE LICENSE PLATE NUMBER SUBJECT OF INQUIRY IS Driver of other vehicle Owner of other vehicle SECTION 5 -- PERJURY STATEMENT DATE PRINTED NAME SIGNATURE X FOR DMV USE ONLY The subject of your inquiry: submitted evidence of liability insurance with . , an authorized self-insurer (SI # ) ) exempt from the reporting requirement. has not submitted evidence of liability insurance in effect at the time of the accident. The accident does not come under the authority of the Financial Responsibility Law; the SR 1 indicates there was no damage over $1,000 ($750 for accidents prior to January 1,2017) and no injury or fatality. Your request does not (please furnish information checked above): state your interest in the case. Other: FR Information Request cannot be processed because SR 1 was received over one year after the accident. . The driver involved in this accident provided DMV with insurance information or was driving an employer's vehicle. Under these circumstances, the department will not solicit information from the registered owner/employer. The vehicle was reported "Parked;" therefore, insurance information was not solicited. DMV does not maintain insurance for all vehicles registered in California. Insurance information, when needed, is requested upon receipt of an SR 1 following a reportable accident occurring in California. If you resubmit this request, an additional $20 fee is due. SR 19C (REV. 1/2017) WWW was driving a vehicle owned by American LegalNet, Inc. www.FormsWorkFlow.com FINANCIAL RESPONSIBILITY INFORMATION REQUEST INSTRUCTIONS Pursuant to CVC §16005, accident information can be released only to individuals who have a proper interest in the accident: a driver, his/her parent, employer, or legal guardian; authorized representatives for these individuals; an injured party; an owner of vehicle/property damaged in the accident; courts; and law enforcement agencies. COMPLETE THE FIELDS AS FOLLOWS: SECTION 1 -- TYPE OF INFORMATION REQUESTED Check the appropriate box indicating the type of information you are SECTION 2 -- REQUESTER'S INFORMATION Provide the following: · · Return Address ­ Print your name, address, and telephone number . Vendor Information ­ If you have a commercial requester account with DMV that entitles you to receive accident information and you wish to have your account billed through Automated Billing Information Service (ABIS) in lieu of remitting the appropriate fee(s), complete the Vendor Requester Code Number, Vendor Agreement Number, and Vendor Name. Explain Your Interest in This Accident ( ) ­ Check the appropriate box to show your interest in this accident. If · accident-related information until you establish that you are entitled to it. SECTION 3 -- ACCIDENT-RELATED OR CLIENT INFORMATION · · · · · Date of Request ­ Write in the date of your request. FR File Number ­ Provide the DMV FR Case number, if known. If not, leave blank. Accident Date/Location Your Client or Insured an individual driver/owner involved in the accident, provide the client's name. Name of Driver of Vehicle you or your Client Were in ­ Write in the name of the individual driving the vehicle your client or insured was driving or riding in (write in your name if you were the driver). ­ ­ If you or your client were an injured pedestrian or bicyclist, or the owner of property damaged in the accident, leave Provide the following information regarding the individual who was driving the car you or your client was in, or the property owner, injured pedestrian, or bicyclist, whichever applies: · Driver License/ID Card Number, Birth Date, and Address SECTION 4 -- SUBJECT OF INQUIRY Complete the name, birth date, address, driver license/ID card number, and license plate number of the person whose insurance Indicate by checking the appropriate box whether the subject of inquiry is the driver or the owner of the other vehicle. SECTION 5 -- PERJURY STATEMENT Before any accident-related information can be released, you must declare, under penalty of perjury, that you are entitled to the FOR DMV USE ONLY FEES ­ A nonrefundable $20 fee is required for each document requested. A separate request form should be used for each item requested; however, if one form is used to request multiple items related to a single accident, each one requires a fee (i.e. $40 for two items, $60 for three, etc.). Please make check or money order payable to DMV. Please allow 30 days for processing. If you have any questions regarding the completion of this form, contact our customer service representatives at (916) 657-6677. SR 19C (REV. 1/2017) WWW American LegalNet, Inc. www.FormsWorkFlow.com