New York State Department of Motor Vehicles MOTOR VEHICLE RECORD SEARCH ACCOUNT APPLICATION u u http://dmv.ny.gov/dial-in Email: DataServices@dmv.ny.gov Before you begin, please review the Terms of Service on page 3. If you are opening a new account for a commercial or not-for-profit organization, attach an opening deposit. The deposit amount should fund your estimated usage for two months. Electronic searches are $7 each. Mail order searches are $10 or more, depending on what kinds of certified documents you request. Please make your check or money order payable to "Commissioner of Motor Vehicles". If you are opening a new account for a: u government organization; u volunteer fire company; u volunteer ambulance service; u u legal aid bureau or society or other private entity when acting pursuant to Section 722 of the New York State County Law; and you will be using the information obtained for a public purpose, complete the Fee Exemption Certification on page 4 to claim the exemption from search fees under Section 202 of the New York State Vehicle and Traffic Law. You must also provide evidence of your government employment or your affiliation with the exempt organization, such as a pay stub or an official letter from the organization. u If you represent a commercial or not-for-profit organization (including volunteer fire companies and volunteer ambulance services), include a certified copy of your business certificate. Send the form to: DATA SERVICES - NEW SEARCH ACCOUNT NYS DEPARTMENT OF MOTOR VEHICLES 6 EMPIRE STATE PLAZA ALBANY NY 12228 u ACCOUNT INFORMATION (Please Print or Type) Please mark one of the following boxes to indicate which service you are requesting: o Open new account o Update information for an existing account. DMV will need your account number to process any changes. ACCOUNT #:_____________________________ Applicant: ________________________________________________________________________________________ Applicant's Driver License Number: _________ - _________ - _________ State/Province: ______________________ Organization: ______________________________________________________________________________________ Address: __________________________________________________________________________________________ City: __________________________________________________ State: _________ Zip Code: ____________________ Telephone: _______ - _______ - __________ Ext. ____________ Fax: _______ - _______- __________ (DO NOT GIVE P.O. BOX) Email Address: ____________________________________________________________________________________ Federal Employer ID Number: Please describe in detail how you plan to use the information from searches of DMV's records: If DMV has ever terminated a search account held by you, your organization, or any principal, agent, officer or employee associated with your organization, please provide the account number(s): _________________________________________________________________________________________________ MV-15D (8/13) www.dmv.ny.gov PAGE 1 OF 4 American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATION OF PERMISSIBLE USES The Federal Driver's Privacy Protection Act (18 U.S.C. §2721.et seq.) ("DPPA") regulates access to Motor Vehicle records. Recipient hereby certifies that the information provided hereunder by DMV shall be used solely for the following purpose(s). (Recipient must check all that apply) 1. ___ Use by any government agency including any court or law enforcement agency, in carrying out its functions. (18 U.S.C. §2721 (b)(14)) 2. ___ 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. §2721 (b)(1)) 3. ___ Use in matters of motor vehicle or driver safety. (18 U.S.C. §272 (b)(2)) 4. ___ Use in matters of motor vehicle theft. (18 U.S.C. §2721 (b)(2)) 5. ___ Use in matters of motor vehicle emissions. (18 U.S.C. §2721 (b)(2)) 6. ___ Use in matters of motor vehicle product alterations, recalls or advisories. (18 U.S.C. §2721 (b)(2)) 7. ___ Use in performance monitoring of motor vehicles, motor vehicle parts and dealers. (18 U.S.C. §2721 (b)(2)) 8. ___ Use in motor vehicle market research activities, including survey research (18 U.S.C. §2721 (b)(2)) 9. ___ Use in removal of non-owner records from the original owner records of motor vehicle manufacturers. (18 U.S.C. §2721 (b)(2)) 10. ___ For use in the normal course of business by a legitimate business or its agents, employees, or contractors, but only(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. §2721 (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. §2721 (b)(3)(B)) 11. ___ 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. §2721 (b)(4)) 12. ___ Use by an insurer or insurance support organization or self-insured entity in claims investigations, anti-fraud activities, rating or underwriting activities. (18 U.S.C. §2721 (b)(6)) 13. ___ Use in providing notice to the owners of towed or impounded vehicles.(18 U.S.C. §2721 (b)(7)) 14. ___ Use by an employer, its agent or insurer to obtain information relating to the holder of a commercial driver license required under Chapter 313 of Title 49 of the U.S.C.) (18 U.S.C. §2721 (b)(9)) 15. ___ Use in the operation of private toll transportation facilities. (18 U.S.C. §2721 (b)(10)) 16. ___ Use by any requester, if the requester demonstrates it has obtained the written consent of the individual to whom the information pertains. (May use form MV-25GC)(18 U.S.C. §2721 (b)(13)) 17. ___ Use required under NYS Vehicle and Traffic Law, Article 19-A -- Special Requirements for Bus Drivers. (18 U.S.C. §2721 (b)(14)) 18. ___ Use required under NYS Vehicle and Traffic Law, Article 19-B -- Special Requirements for Commercial Motor Carriers. (18 U.S.C. §2721 (b)(14)) 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 N