OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES OBMV RECORD REQUEST (Ohio Revised Code [R.C.] 4501.15, 4501.27, AND 4507.53) This agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under R.C. 4501.27. Disclosure of this information is REQUIRED. FAILURE to provide any information will result in this form not being processed. This request is being made by (check one): An individual inquiring regarding himself or herself: (Complete Part A) If inquiring in person for information on yourself, you must provide personal information regarding yourself, or prove your identity by presenting your driver license or identification card. An individual inquiring regarding another person: (Complete Parts A and B) If inquiring regarding another individual, you must attach a notarized BMV Form 5008 giving the written consent of the person. All mail requests without the BMV Form 5008 attached will be returned to the requester. Other: (Check applicable reason for request on Part C, and complete Parts A and B) I am requesting the following personal information contained in the Bureau of Motor Vehicles records: Driving Record [302] Last Known Address [405] (Mail in Only) Cosigner w / Date of Loss-________ [405] (Mail in Only) Copy of Driver License Application [405A] ($5.00) ($5.00) ($5.00) ($5.00) Copy of Title Record Vehicle Registration Record [303] ($5.00) ($5.00) PART A: Please provide current information regarding yourself: YOUR NAME (REQUESTER) COMPANY NAME (IF APPLICABLE) CURRENT STREET ADDRESS TELEPHONE # / FAX # *SOCIAL SECURITY # (OPTIONAL) VEHICLE IDENTIFICATION # (IF APPLICABLE) NOTE: SIGNATURE REQUIRED SIGNATURE DATE BMV ACCOUNT # (IF APPLICABLE) DATE OF BIRTH X CITY **EMAIL ADDRESS (PLEASE PRINT LEGIBLY) DRIVER LICENSE # (IF APPLICABLE) LICENSE PLATE # (IF APPLICABLE) STATE ZIP TITLE # (IF APPLICABLE) PART B: Request regarding other person(s): PERSON'S NAME STREET ADDRESS *SOCIAL SECURITY # (OPTIONAL) VEHICLE IDENTIFICATION # CITY DRIVER LICENSE # TITLE # DATE OF BIRTH STATE ZIP LICENSE PLATE # If requesting information on more than 1 person or vehicle, attach additional sheet(s): Additional sheet(s) attached Make check or money order payable to Ohio Treasurer of State. If mailing, return to: Ohio Bureau of Motor Vehicles, Attn: BMV Records, P.O. Box 16520, Columbus, Ohio 43216-6520. Results will be sent to requester. * It is not necessary that you provide a Social Security #. However, in order to best assist you with your request, please provide the Ohio BMV with as many identifiers as possible. ** If you would like the BMV to email your record request: Email my record request (Include valid email address above) Please Note ­ Due to security concerns, if the email address you provided is invalid, the record(s) will be mailed to the requestor's address listed in Part A. BMV 1173 7/14 [760-1060] Page 1 of 2 PUBLIC American LegalNet, Inc. www.FormsWorkFlow.com Part C: I (requester) qualify as checked below, and I am requesting: 1. 2. As an individual. (Complete Part A, front) A record for use in the normal course of business by me as a legitimate business or an agent, employee, or contractor of a legitimate business, for one of the two following purposes: (a) to verify the accuracy of personal information submitted to the business, agent, employee, or contractor by an individual; (b) in case personal information submitted to the business, agent, employee, or contractor by an individual is incorrect or no longer is correct, to obtain the correct information, for the sole purpose of preventing fraud, by pursuing legal remedies against, or recovering on a debt or security interest against, the individual. My tax identification number is: __________ My vendor number is: __________ My professional license number is: __________ Licensed by (agency): __________ With written consent. (Complete Parts A and B, front). Records for bulk distribution for surveys, marketing, or solicitations, where the information will be used, rented, or sold solely for bulk distribution for surveys, marketing, or solicitations; A record for the use of a government agency, including, but not limited to, a court or law enforcement agency, in carrying out its functions, or for the use of a private person or entity acting on behalf of an agency of this state, another state, the United States, or a political subdivision of this state or another state in carrying out its functions (a law enforcement agency does not need to fill out this form); A record for use in connection with matters regarding motor vehicle or driver safety and theft; motor vehicle emissions; motor vehicle product alterations, recalls, or advisories; performance monitoring of motor vehicles, motor vehicle parts, and dealers; motor vehicle market research activities, including, but not limited to, survey research; and removal of non-owner records from the original owner records of motor vehicle manufacturers. Please provide relevant documentation supporting your request.; A record for use in connection with a civil, criminal, administrative, or arbitral proceeding in a court or agency of this state, another state, the United States, or a political subdivision of this state or another state or before a self-regulatory body, including, but not limited to, use in connection with the service of process, investigation in anticipation of litigation, or the execution or enforcement of a judgment or order (a subpoena or other court order may be used instead of this form). Please provide the court and case number, or if the case has not yet been filed, the court you anticipate to file in __________ ; A record pursuant to an order of a court of this state, another state, the United States, or a political subdivision of this state or another state (a subpoena or other court order may be used instead of this form). Please attach a certified copy of the court order: Records for use in research activities or in producing statistical reports, where the personal information will not be published, redisclosed, or used to contact an individual. Please provide a detailed description of your research activities and identify the business, educational institution, or other entity for which you are doing the research; Records for use by an insurer, insurance support organization, or self-insured entity, or by an agent, employee, or contractor of that type of entity, in connection with a claims investiga