Fillable Printable Form DS-19 - Motor Carrier Accident and Conviction Notification Program Application - New York

Form DS-19 - Motor Carrier Accident and Conviction Notification Program Application - New York

ARTICLE 19-A MOTOR CARRIER ACCIDENT AND

CONVICTION NOTIFICATION PROGRAM APPLICATION

(Escrow Account & Driver’s Privacy Protection Act Compliance)

INSTRUCTIONS:

1. The Carrier must complete all sections on page 1 and page 2 of this form. Please print clearly.

2. Review the opening deposit table below to determine the required opening escrow deposit amount.

Article 19-A of the New York State Vehicle and Traffic Law (VTL), Section 509-i(4) requires all motor carriers to establish an escrow

account which shall be used to pay for the costs incurred by DMV when it informs the motor carrier of a driver’s conviction or accident.

3. Make your check or money order payable to “Commissioner of Motor Vehicles” (never send cash) and mail it with this

completed form to:

NYS Department of Motor Vehicles, Bus Driver Unit, 6 Empire State Plaza, Room 136B, Albany, NY 12228.

Motor Carrier Information:

Motor Carrier’s Name: ________________________________________________________________________________________

Address: ____________________________________________________________________________________________________

City: ____________________________________________________ State ___________ Zip Code: ______________________

Federal Employer ID Number (FEIN):

Location where the Motor Carrier maintains drivers’ records for audit:

Address: ____________________________________________________________________________________________________

City: _______________________________________________________ State: _________ Zip Code: ________________________

Telephone: _____________________________ ext. ________ Fax: (optional) ______________________________ ext. ________

E-Mail: ___________________________________________________________________ (optional)

Person responsible for maintaining the 19-A records of the Motor Carrier’s drivers:

Name:____________________________________________________________________________________________________

Telephone: ___________________________ ext. ________

DS-19 (3/15)

PAGE 1 OF 2

Number of drivers to enroll in the 19-A program

Opening Deposit to send to DMV

0 to 25 $10.00

25.00

40.00

50.00

70.00

26 to 65

66 to 115

116 to 225

More than 225

Person responsible for billing

Name: __________________________________________________________________________________________________

Address: ________________________________________________________________________________________________

City: _______________________________________________________ State: _________ Zip Code: ____________________

Telephone: ___________________________ ext. ________ Fax: (optional) _____________________________ ext. ________

E-Mail: _________________________________________________________________ (optional)

FOR

DMV OFFICE

USE

( ) ( )

DMV approval by: (Sign)

Print Name:

Title:

Date (mm/dd/yyyy):

( )

DS-19 (3/15)

www.dmv.ny.gov

PAGE 2 OF 2

On the _____________ day of ______________________ , in the year 20 ________ , before me personally came

___________________________________________________ , to me known who, being by me duly sworn, did depose and

say that s/he resides in ______________________________________________________________ (county, state); that s/he is the

______________________________ (e.g., president, officer, director, managing member, attorney in-fact) and duly authorized

representative of ____________________________________________________, the business entity (principal) described in and

which executed the above instrument; and that s/he signed his/her name thereto on behalf of said business entity (principal), and

within the scope of his/her authority to bind said principal to the terms of the foregoing Agreement.

Notary Public

1. The Motor Carrier will only request and use information provided by DMV as specifically authorized under federal and NYS

laws, where the requested information is related to the operation of the carrier’s drivers’ motor vehicle records or public safety

(DPPA 2721 (b)(14); VTL, Article 19-A - Special requirements for Bus Drivers); the carrier will advise its pertinent personnel of

their obligations thereunder, and will ensure that personal information provided by DMV is not accessed, used or disseminated

for unauthorized purposes.

2. Information which is provided electronically to the Motor Carrier is also subject to the New York State Information Security

Breach and Notification Act

(ISBNA) (G.B.L. §899-aa; State Technology Law, §208). DMV is required to notify individuals if

their records are accessed for unauthorized purposes. The Motor Carrier must report suspected or confirmed violations of the

DPPA or ISBNA to the DMV Information Security Office, within one (1) business day of discovering any such violation, by

email to [email protected], or by telephone at (518) 402-2676. The Motor Carrier shall be responsible for all

costs associated with providing notices required under the ISBNA.

3. The Motor Carrier must keep, for a period of 5 years, records identifying each person or entity that receives personal information

from DMV, and the date, time and purpose for which the information was used and accessed. The Motor Carrier will cooperate

with any audit of such records by DMV or the State. The Motor Carrier must make such records available to DMV for audit

purposes. If the Motor Carrier does not have an office location in New York State, it must forward to DMV all records requested,

at the time, place and location designated by DMV. The Motor Carrier must promptly notify the DMV in writing of any change

of its name, or the physical address where the pertinent records will be maintained.

4. The State shall not be responsible for any omissions or errors in the information furnished to the Motor Carrier by DMV.

5. The Motor Carrier shall indemnify, keep and hold harmless the State of New York, its agents, officials and employees from any

and all claims for injury or damage to person or property, deaths, losses, damages, suits arising out of the negligent, improper, or

unauthorized use or dissemination by the Motor Carrier, its officers, employees or agents of personal information provided by DMV.

6. In the event of any suspected or confirmed breach of the security of personal information provided by DMV, DMV reserves the

right and sole discretion to suspend or terminate the Motor Carrier’s access to personal information from motor vehicle records

maintained by DMV.

The Federal Driver’s Privacy Protection Act (DPPA) (18 USC. Sec. 2721 et seq.) regulates the access, disclosure, and

dissemination of personal information contained in motor vehicle records maintained by DMV. DPPA, Section 2721 (b)(14)

permits Article 19-A Motor Carriers to gain access to their drivers’ records for the sole purpose complying with state and

federal laws governing the carrier’s obligation to protect public safety.

THE UNDERSIGNED MOTOR CARRIER CERTIFIES UNDER PENALTY OF PERJURY THAT IT HAS READ AND UNDERSTOOD

THE FOREGOING AND THAT ALL INFORMATION PROVIDED IN THIS APPLICATION IS TRUE AND ACCURATE.

By submitting this application to participate in the Accident and Conviction Notification Program, the undersigned Motor

Carrier acknowledges and certifies as follows:

NOTARY ACKNOWLEDGEMENT:

STATE OF NEW YORK )

) ss:

COUNTY OF____________________ )

Carrier’s Name: ________________________________________________________________________________________,

by its duly authorized representative (Owner/General Partner/duly authorized Corporate Office/LLC Managing Member/School Superintendent)

Representative’s Name (Sign)

Print Name:

Title:

Date (mm/dd/yyyy):

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