FREEDOM OF INFORMATION LAW REQUEST FORM002 FREEDOM OF INFORMATION LAW REQUEST FOR DMV RECORDS MAKE SURE YOU USE THE CORRECT FORM TO REQUEST RECORDS! You will receive your records more quickly when you use the correct request form. DMV forms are available at dmv.ny.gov DO NOT USE THIS FORM TO REQUEST THE FOLLOWING RECORDS: 002Driver license record (215abstract216) - use form MV-15 002Vehicle title record - use form MV-15 002Driver history (215lifetime abstract216) - use form MV-15 002Copy of a ticket and/or ticket disposition - use form MV-15 002Vehicle registration record (215abstract216) - use form MV-15 002Copy of a revocation or suspension order - use form MV-15 002Accident report - use form MV-198C 1. Information About You (the Requestor):B Name Organization (if applicable) Address (Number and Street) City State ZIP Code E-mail Address (Required if you want your records sent to you electronically)* Phone Number (optional) ( ) *Records sent by email or by fax will not be certified. Certified records must be mailed. We can only provide your records by one method (mail, email, or fax). 2. Important Information About Requests for Certain DMV Records: Personal information on certain DMV records is protected by the Federal Driver220s Privacy Protection Act (18 U.S.C. 2472721 et seq.) and by 24787 and 24789 of the NYS Public Officers Law. Records about a driver license or permit, motor vehicle title, motor vehicle registration, or identification card issued by DMV are protected by the Driver220s Privacy Protection Act. If any of the records you want are protected by the Driver220s Privacy Protection Act, you must do the following: 1.J Mark your permissible use in the list on page 3 of this form; 2.J Send a photocopy of your driver license or government-issued non-driver ID card with this form (you can cover the photo Bon the document); andB 3.J Sign the certification on the bottom of page 3. MV-FOIL (6/18)0 PAGE 1 OF 3 American LegalNet, Inc. www.FormsWorkFlow.com FREEDOM OF INFORMATION LAW REQUEST FORM002 3. Describe the DMV Records That You Want: Please provide as much detail as possible about the records you are requesting. You may attach additional sheets if necessary. YOU CANNOT USE THIS FORM TO REQUEST YOUR LIFETIME ABSTRACT. YOU MUST USE FORM MV-15! 4. Fee Information: Section 202 of the NYS Vehicle and Traffic Law requires a $10 search fee and a copy fee of $1 per page. You must send a $10 search fee with your FOIL request, unless you or your organization is exempt from these fees. Only these groups are exempt from search fees: 002Government agencies 002Volunteer fire companies 002Volunteer ambulance services 002Public officers, boards, or bodies 002Legal aid bureaus or societies or other private entities when acting pursuant to 247722 of the New York State County Law 5. Method of Payment:B Check the box that shows your payment method. If you pay with a credit card, you must sign on the Authorized Signature line to authorize DMV to charge your card. 003Exempt (Check this box ONLY if you belong to one of the exempt groups described in the Fee Information section above.) 003Check 003Money Order 003DMV Escrow Account 003Credit Card: 003MasterCard 003Visa 003American Express 003Discover Card Credit Card Number: Expiration Date: Zip Code Associated with Credit Card: Security Code: Authorized Signature X 3 or 4 digit code on the back or front of your card MV-FOIL (6/18) PAGE 2 OF 3 American LegalNet, Inc. www.FormsWorkFlow.com Mail or email your request to: XNEW YORK STATE DEPARTMENT OF MOTOR VEHICLES List of Permissible UsesB Driver Privacy Protection ActB 004 Step 1) Check the permissible use(s) for the records that you want:J The Federal Driver220s Privacy Protection Act (18 U.S.C. 2472721.et seq.) (215DPPA216) regulates access to Motor Vehicles records. Recipienthereby certifies that the information provided hereunder by DMV shall be used solely for the following purpose(s). 1. (Recipient must check all that apply.) Use in any civil, criminal, administrative, or arbitral proceeding in any court or agency, 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. (18 U.S.C. 2472721 (b)(4)) 2.Use by an insurer or insurance support organization or self-insured entity in claims investigations, anti-fraud activities, rating orunderwriting activities. (18 U.S.C. 2472721 (b)(6))3.Use in providing notice to the owners of towed or impounded vehicles. (18 U.S.C. 2472721 (b)(7))4.Use by an employer, its agent or insurer to obtain information relating to the holder of a commercial driver's license required underChapter 313 of Title 49 of the U.S.C. (18 U.S.C. 2472721 (b)(9))5.For use in the normal course of business by a legitimate business or its agents, employees, or contractors, but onlyQ(A) to verify the accuracy of personal information submitted by the individual to the business or its agents, employees, or contractors; (18 U.S.C. 2472721 (b)(3)(A)) and (B) if such information as so submitted is not correct or is no longer correct, to obtain the correct information, but only for the purposes of preventing fraud by, pursuing legal remedies against, or recovering on a debt or security interest against, the individual. (18 U.S.C. 2472721 (b)(3)(B)) 6.Use required under NYS Vehicle and Traffic Law, Article 19A - Special Requirements for Bus Drivers. (18 U.S.C. 2472721 (b)(14))7.Use required under NYS Vehicle and Traffic Law, Article 19B - Special Requirements for Commercial Motor Carriers.(18 U.S.C. 2472721 (b)(14))8.Use by any government agency, including any court or law enforcement agency, in carrying out its functions. (18 U.S.C. 2472721 (b)(1))9.Use by any private person or entity acting on behalf of a federal, state, or local agency in carrying out its functions.(18 U.S.C. 2472721 (b)(1))10.Use in matters of motor vehicle or driver safety. (18 U.S.C. 2472721 (b)(2))11. Use in matters of motor vehicle theft. (18 U.S.C. 2472721 (b)(2))12.Use in matters of motor vehicle emissions. (18 U.S.C. 2472721 (b)(2))13.Use in matters of motor vehicle product alterations, recalls or advisories. (18 U.S.C. 2472721 (b)(2))14.Use in performance monitoring of motor vehicles, motor vehicle parts and dealers. (18 U.S.C. 2472721 (b)(2))15.Use in motor vehicle market research activities, including survey research. (18 U.S.C. 2472721 (b)(2))16.Use in removal of non-owner records from the original owner records of motor vehicle manufacturers. (18 U.S.C. 2472721 (b)(2))17.Use in the operation of private toll transportation facilities. (18 U.S.C. 2472721 (b)(10))18.For use by any requester, if the requester demonstrates it has obtained the written consent of the individual to whom the informationpertains. (May use form MV-15GC). (18 U.S.C. 2472721 (b)(13))19.Use specifically authorized under NYS law, IF such use is related to the operation of a motor vehicle or public safety.Cite the specific NYS law here:(18 U.S.C. 2472721 (b)(14)) 20.Use in research activities and in producing statistical reports, as long as the personal information is not published, disclosed orused to contact individuals. (18 U.S.C. 2472721 (b)(5))To knowingly make a false statement or conceal a material fact in this written statement is a criminal offense, punishable under PenalLaw 247210.45. In addition, anyone who makes false representation to obtain any personal information from an individual220s MotorVehicles record is subject to federal criminal fines under the Driver220s Privacy Protection Act (DPPA). 004Step 2) Attach a copy of your driver license or government-issued identification card. (You may cover the picture.) 004Step 3) Sign the following Privacy Certification: I certify that I have read the Driver220s Privacy Protection Act (18 U.S.C. 2472721 et seq.) and will comply fully with the terms of such law. Ialso certify that I shall not request or use any information provided by the Department of Motor Vehicles that is not specificallyauthorized by the Driver220s Privacy Protection Act. Requester220s Signature (required)J Date Requester -Print Name Here FREEDOM OF INFORMATION