OHIO BUREAU OF MOTOR VEHICLES RECORD CONFIDENTIALITY WAIVER A. MAIL OFFER OPT-IN The Ohio Bureau of Motor Vehicles does not release personal information to businesses for bulk distribution for surveys, marketing and solicitations. However, if you wish to authorize the release of your name and address and other personal information to businesses for these purposes, you may do so. Do you wish to authorize the release of this information? Yes No B. INDIVIDUAL LOOK-UP OPT-IN The Ohio Bureau of Motor Vehicles does not release personal information to other individuals who request it. However, if you wish to authorize the release of your name and address and other personal information to other individuals, you may do so. Do you wish to authorize the release of this information? Yes No C. MEDICAL AND DISABILITY INFORMATION OPT-IN The Ohio Bureau of Motor Vehicles does not release personal information to other individuals, businesses, and others who request it. However, if you wish to authorize the release of your medical and disability information to others who request it, you may do so. Do you wish to authorize the release of your medical and Yes No disability information to individuals, businesses, and others who request it? (PLEASE PRINT) NAME SOCIAL SECURITY NUMBER TITLE NUMBER DRIVER LICENSE NUMBER DATE OF BIRTH LICENSE PLATE NUMBER VEHICLE IDENTIFICATION NUMBER 1. The Ohio Bureau of Motor Vehicles will provide personal information only within the limits of the law depending on the information that you provide above. 2. Only individuals may authorize release of this information. 3. Information regarding joint applications will be provided for both individuals. 4. The information on this form will take effect after it is received by the Ohio Bureau of Motor Vehicles in Columbus and is processed. 5. Mail to: Ohio Bureau of Motor Vehicles, Attn: License Support Services, P. O. Box 16520, Columbus, Ohio 43216-6520. X Signature: ___________________________________________ Date: _________________ INCOMPLETE FORMS WILL NOT BE PROCESSED OR RETURNED. FOLD BEFORE MAILING BMV 2095 8/12 [760-1096] PUBLIC American LegalNet, Inc. www.FormsWorkFlow.com FOLD HERE FIRST PLACE STAMP HERE OHIO BUREAU OF MOTOR VEHICLES ATTN LICENSE SUPPORT SERVICES P O BOX 16520 COLUMBUS OH 43216-6520 FOLD HERE SECOND DO NOT STAPLE American LegalNet, Inc. www.FormsWorkFlow.com TAPE HERE