GENERAL CONSENT FOR RELEASE OF PERSONAL INFORMATION Background The federal Driver's Privacy Protection Act (DPPA) designates certain information in motor vehicle records as Personal Information. Personal information includes a motorist's photograph, social security number, date of birth, driver license number, non-driver ID number, name, address (except for 5-digit zip code), telephone number, and medical or disability information. Public information includes reportable accidents, driving convictions, driver status and vehicle information. Most motor vehicle records contain personal and public information. Please note, if we are authorized to release personal information, we will not release social security number, phone number, photograph, medical or disability information. The DPPA also limits the reasons (permissible uses) for which the Department of Motor Vehicles may release records containing personal information. A copy of the DPPA, and the permissible uses in New York State, are printed on form MV-15DPPA . Some requesters may request a copy of a record only if they have permission from the person named in the record. This form provides evidence (signed authorization) of that permission. Instructions for Motorists The motorist is the person named in a motor vehicle record. The record requester is the person requesting information about the motorist. To complete this form, print your name in the blank marked Motorist. Print the record requester's name in the blank marked Record Requester. Then visit a notary public. In the presence of the notary, sign on the line marked Motorist's Signature, then give this form to the notary to notarize. After it is notarized, give this form to the record requester. Instructions for Record Requesters You may request someone else's motor vehicle record containing personal information only if you have a permissible use as defined in the DPPA. You may face criminal penalties and civil liabilities if you request a record for which you do not have a permissible use. Having the motorist's permission is a permissible use. This form, properly completed and notarized, is evidence of the motorist's permission. Keep a copy of this form for five years after you receive the record you requested. I, ______________________________________________, authorize the New York State Department of Motor Vehicles (Motorist) to disclose or otherwise make available to__________________________________________ personal information about (Record Requester) me obtained by the Department in connection with a motor vehicle record. ç STATE OF ___________________________________________ COUNTY OF _________________________________________ Motorist's Signature ss: On this _______________ day of ____________________________ , ____________ before me personally appeared (month) (year) ___________________________________________ , to me known and who by me being duly sworn, acknowledged (Motorist) to be the person described in and who executed the foregoing consent and who acknowledged to me that he/she executed the same for the purpose therein stated. Notary Public MV-15GC (10/16) dmv.ny.gov American LegalNet, Inc. www.FormsWorkFlow.com