Fillable Printable Form MV-15 - Request for DMV Records - New York

Form MV-15 - Request for DMV Records - New York

TOTAL FEE

__________ No record(s) $ ____________

__________ Abstract(s) $ ____________

__________ Application(s) $ ____________

Ticket(s); Summons(es);

__________ Ticket Disposition(s) $ ____________

__________ Suspension/Revocation Order (LIC) $ ____________

__________ Suspension/Revocation Order (REG) $ ____________

__________ Vehicle & Traffic Law Book(s) $ ____________

Insurance Search/

__________ Insurance Activity Expansion report $ ____________

__________ FS Insurance card or FH Certificate $ ____________

Remember to attach a photocopy of your driver license or government-issued photo ID card (you may black out the picture), or have

your signature in STEP 4 notarized.

We need to identify you, the requester. Provide your name and address in STEP 2 for future reference.

Check the box next to each item you are requesting. You may request more than one.

PART A

PART B

Provide as much information as possible about the motorist or vehicle record(s) that you are requesting.

REQUEST FOR DMV RECORDS

STEP 2

Provide the name and the address where the records are to be mailed

Read and complete steps 1 - 4. We cannot process incomplete forms (forms that do not have enough information to conduct a

diligent search, that have insufficient fees, or that have no identification). Incomplete forms will be returned.

STEP 1

You must tell us why you want the record(s) that you are requesting. Place a check mark next to each

permissible use that applies for the record(s) that you are requesting. Personal information on certain DMV records

is protected by the Federal Driver’

s Privacy Protection Act (18 U.S.C. 2721 er seq) and also by sections 87 and 89 of the NYS

Public Officer’s Law. Records that pertain to a motor vehicle operator’s license, permit, motor vehicle title, motor vehicle

registration, or identification card issued by DMV are protected by the Driver’s Privacy Protection Act. If you are requesting

only your own record(s), you may skip to STEP 4.

Title abstracts or title application photocopies may contain the names of other individuals. If you are

requesting these documents, you must complete STEP 3.

STEP 3

Sign and print your name. Remember to attach a photocopy of your driver license, government-issued

identification card, or have your signature in STEP 4 notarized.

ACCEPTABLE METHOD OF P

AYMENT: Check or money order payable to the Commissioner of Motor Vehicles (no starter

checks accepted - must have name pre-printed), a DMV search account with information filled in or exempt.

Exempt From Fees

: Government agencies; public officers, boards or bodies; volunteer fire companies; volunteer ambulance

services; legal aid bureaus or societies; or any private entity acting pursuant to NY County Law section 722 are exempt.

NOTE: The search fee must be charged for every search even if no records are found.

Mail your completed MV-15 form, identification, and payment to:

NYS Department of Motor Vehicles

MV-15 Processing

6 Empire State Plaza

Albany NY 12228

STEP 4

FINAL

NOTE

PAGE 1 0F 4

MV-15 (9/15)

DMV OFFICE USE ONLY

STEP 1

Print/Type name and mailing address.

Your File Name or Number:

Amount Received

Your return receipt

PLEASE READ THE INSTRUCTIONS BELOW FIRST

REFUND (IF ANY) $

Operator Initials ____________

Date Processed ____________

MV-15 (9/15)

PAGE 2 0F 4

MV-15 (9/15)

o DRIVING ABSTRACT (RECORDS FOR THE LAST 4 YEARS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $10 each

o DRIVING RECORD HISTORY (ALSO CALLED A “LIFETIME ABSTRACT”)

ONLY YOU, OR SOMEONE YOU HAVE GIVEN WRITTEN PERMISSION TO (CHECK BOX #13 ON PAGE 4 AND INCLUDE

FORM MV-15GC), MAY ORDER THIS TYPE OF DRIVING RECORD. EXAMPLES OF WHEN THIS MAY BE REQUIRED

INCLUDE: BACKGROUND CHECKS, BAR EXAM, APPLICANTS FOR A LICENSE IN U.S OR CANADA, AND AN ATTORNEY

REVIEWING CLIENT’S ENTIRE RECORD.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $10 each

o VEHICLE REGISTRATION ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $10 each

o VEHICLE TITLE ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $10 each

o DRIVER LICENSE APPLICATION PHOTOCOPY (AVAILABLE FOR THE LAST 7 YEARS FROM CURRENT DATE). . . . . . . . . . . . $11 each

o VEHICLE REGISTRATION/TITLE APPLICATION PHOTOCOPY (AVAILABLE FOR THE LAST 5 YEARS FROM CURRENT DATE) . . . . . . . . $11 each

o CERTIFIED SUSPENSION OR REVOCATION ORDER PHOTOCOPY (WRITE ORDER # IN PART B BELOW). . . . . . . . . . . . . . . . $11 each

o TICKET/SUMMONS PHOTOCOPY (WRITE TICKET #, DATE OF VIOLATION, AND/OR OFFENSE, IF KNOWN, IN PART B BELOW) . . . . . . $11 each

o TICKET DISPOSITION PHOTOCOPY (WRITE TICKET # OR CASE #, IF KNOWN, IN PART B BELOW). . . . . . . . . . . . . . . . . . . . $11 each

o VEHICLE AND TRAFFIC LAW BOOK (HOW MANY?_______) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 6 each

o INSURANCE INFORMATION SEARCH/INSURANCE ACTIVITY EXPANSION REPORT

REQUIRED: REGISTRANT'S NAME, DATE OF ACCIDENT, VEHICLE YEAR & MAKE, AND PLATE # . . . . . . . . . . . . . . . . . . . . . . $10 each

o FOR-HIRE CERTIFICATE OR FS INSURANCE ID CARD

REQUIRED: REGISTRANT'S NAME; VEHICLE YEAR & MAKE; PLATE#; AND DATE OF ACCIDENT ( IF APPLICABLE)

(AVAILABLE IF ORIGINAL REGISTRATION APPLICATION WAS MADE WITHIN 5 YEARS FROM THE CURRENT DATE). . . . . . $11 each

CHECK THE BOX NEXT TO EACH RECORD THAT YOU ARE REQUESTING (ALL RECORDS ARE CERTIFIED ABSTRACTS OR

CERTIFIED PHOTOCOPIES)

PROVIDE AS MUCH INFORMATION AS YOU KNOW ABOUT THE RECORDS YOU ARE REQUESTING. PLEASE PRINT OR TYPE CLEARLY.

LAST NAME

MAILING ADDRESS (INCLUDE STREET & NO.) APT # CITY STATE ZIP CODE

PLATE NUMBER

VEHICLE YEAR & MAKE VEHICLE IDENTIFICATION NUMBER

DATE OF ACCIDENT TICKET, CASE, OR ORDER NUMBER DATE OF VIOLATION OFFENSE

FIRST M.I. DATE OF BIRTH

SEX N.Y. DRIVER OR NON-DRIVER ID #

MV-15 (9/15)

PAGE 3 0F 4

TO PROCESS YOUR REQUEST, WE NEED TO IDENTIFY YOU, THE REQUESTER.

Attach a copy of your driver license, government-issued photo ID card (you may black out the picture), or have your signature in

Step 4 notarized.

Print your name and return address below, and select the payment method.

Daytime Phone Number (Optional):

STEP 2

PART A

PART B

PAYMENT METHOD l DO NOT SEND CASH l

o DMV Dial-in account number ___________________

o Check o Money Order o Exempt

Payable to the Commissioner of Motor Vehicles

REMEMBER TO ATTACH A COPY OF YOUR ID. (See Step 2 of Instructions.)

I certify that I have read the Drivers Privacy Protection Act (18 U.S.C. Sec 2721 et seq.) and will comply fully with the terms of such

law. I also agree to defend, hold harmless and indemnify DMV from all actions brought against DMV, or damages alleged against

DMV, for my negligent, improper or unauthorized use or dissemination of the information provided by the DMV.

Signature ç

___________________________________________________________________________________

Print Name ___________________________________________________________________________________

STEP 3

STEP 4

MV-15 (9/15)

List of Permissible Uses

Driver Privacy Protection Act

The Federal Driver’s Privacy Protection Act (DPPA) (18 U.S.C. §2721.et seq.) regulates access to DMV records and how the recipients

of motorists’ records subsequently share them. Pursuant to the DPPA, you must have a DPPA Permissible Use to search DMV records.

A list of permissible uses appears below:

(Recipient must check all that apply.)

PAGE 4 0F 4

Date:

1. ____ For use by any government agency, including any court or law enforcement agency, in carrying out its functions, or any private person

or entity acting on behalf of a Federal, State, or local agency in carrying out its functions.

2. ____ For use in connection with matters of 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 survey research; and removal of non-owner records from the original owner records of motor vehicle

manufacturers.

3. ____ 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; 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.

4. ____ For use in connection with any civil, criminal, administrative, or arbitral proceeding in any Federal, State, or local court or agency or

before any self-regulatory body, including the service of process, investigation in anticipation of litigation, and the execution or

enforcement of judgments and orders, or pursuant to an order of a Federal, State, or local court.

5. ____ For use in research activities and for use in producing statistical reports, so long as the personal information is not published, re-

disclosed, or used to contact individuals.

6. ____ For use by any insurer or insurance support organization, or by a self-insured entity, or its agents, employees, or contractors, in

connection with claims investigation activities, anti-fraud activities, rating or underwriting.

7. ____ For use in providing notice to the owners of towed or impounded vehicles.

8. ____ For use by any licensed private investigative agency or licensed security service for any purpose permitted under this subsection.

9. ____ For use by an employer or its agent or insurer to obtain or verify information relating to a holder of a commercial driver’s license

that is required under Chapter 313 of title 49 [49 U.S.C. §31301 et seq.].

10. ____ For use in connection with the operation of private toll transportation facilities.

11. ____ For any other use in response to requests for individual motor vehicle records if the State has obtained the express consent of the

person to whom such personal information pertains.

12. ____ For bulk distribution for surveys, marketing or solicitations if the State has obtained the express consent of the person to whom such

personal information pertains.

13. ____ For 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-15GC)

14. ____ For any other use specifically authorized under the law of the State that holds the record, if such use is related to the operation of a

motor vehicle or public safety.

To knowingly make a false statement or conceal a material fact in this written statement is a criminal offense, punishable under Penal Law Section

210.45. In addition, anyone who makes false representation to obtain any personal information from an individual’s Motor Vehicles record is subject

to federal criminal fines under the Driver’s Privacy Protection Act (DPPA).

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