Fillable Printable Form MV-15C - Request for Driving Record Information - New York

Form MV-15C - Request for Driving Record Information - New York

New York State Department of Motor Vehicles

REQUEST FOR DRIVING RECORD INFORMATION

INSTRUCTIONS:

w A separate form, MV-15C, must be used for each search requested.

w You must show documents to prove your identity (see form ID-44 for acceptable proofs of identity).

Driver records contain the following information:

convictions, suspensions, revocations, accidents, accident prevention course completion (for more information, refer to form DS-242.1)

DMV records do not contain the following information:

tickets, address history, convictions and/or accidents beyond their retention period, date first licensed, vehicle information

You can request your record.

You can request another person’s record.

MV-15C (6/13)

FOR OFFICE USE ONLY

Proof of Identification Provided by Requester:

o Driver License/Non-Driver ID Card o Cash o Check o Credit Card

Client ID #

o Other ID (Specify):

Proof of Qualification for a No Fee Abstract:

THE SPACE BELOW THE LINE IS FOR VALIDATION PURPOSES ONLY.

Name of Organization

Claiming Exemption

o Exempt

Purpose of the

Abstract Request

MVR

Signature

Initials

Date

The Vehicle and Traffic Law requires that DMV charge a $10 search fee. You must pay the fee even if the driver record is not found.

You can pay the fee with a check made payable to “Commissioner of Motor Vehicles”. According to section 202 of the Vehicle and Traffic Law,

the fee to search a record is not charged to: any public officer, board or body; a volunteer fire company; a volunteer ambulance service; a legal

aid bureau, society or private entity that acts pursuant to Section 722 of the County Law.

If DMV can not find a license record with the information you provide, DMV will send you written notification to advise you that the

requested record was not found.

INFORMATION ABOUT THE DRIVER RECORD YOU REQUEST:

YOUR INFORMATION:

Your Signature (required)

Date

PAGE 1 OF 2

CREDIT CARD AUTHORIZATION

My signature authorizes the use of my credit card for payment of any fees in connection with this request. I understand that I must be present for this transaction.

Sign Here ç

(Cardholder-Sign Name in Full)

I request my own record.

(Complete Section A ONLY)

I request another person’s record. (Complete Section A and Section B).

You must write your initials next to the “permissible use” that applies to your request on Page 2 of this form.

Sign Here ç

STREET ADDRESS

CITY OR TOWN

STATE

ZIP CODE

SEX

APT. #

DATE OF BIRTH

NAME (Last, First, Middle)

DRIVER LICENSE ID#

M o F o

Month Day Year

SEX

DATE OF BIRTH

M o F o

Month Day Year

NAME (Last, First, Middle)

Date

The Federal Driver’s Privacy Protection Act (18 U.S.C. §2721.et seq.) (“DPPA”) regulates access to Motor Vehicles records.

Recipient hereby certifies that by placing your initials below, that the information provided hereunder by DMV shall be used

solely for the following purpose(s).

1. ____ 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))

2. ____ 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))

3. ____ Use in providing notice to the owners of towed or impounded vehicles. (18 U.S.C. §2721 (b) (7))

4. ____ Use by an employer, its agent or insurer to obtain information relating to the holder of a commercial driver's license

required under Chapter 313 of Title 49 of the U.S.C. (18 U.S.C. §2721 (b) (9))

5. ____ 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 (18 U.S.C. §2721 (b) (3) (A))

(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))

6. ____ Use required under NYS Vehicle and Traffic Law, Article 19A - Special Requirements for Bus Drivers.

(18 U.S.C. §2721 (b) (14))

7. ____ Use required under NYS Vehicle and Traffic Law, Article 19B - Special Requirements for Commercial Motor Carriers.

(18 U.S.C. §2721 (b) (14))

8. ____ Use by any government agency including any court or law enforcement agency, in carrying out its functions.

(18 U.S.C. §2721 (b) (1))

9. ____ 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))

10. ____ Use in matters of motor vehicle or driver safety.

(18 U.S.C. §2721 (b) (2))

11. ____ 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). (18 U.S.C. §2721 (b) (13))

12. ____ Use specifically authorized under NYS law, IF such use is related to the operation of a motor vehicle or public safety.

Cite the specific NYS law here: ________________________________________________________

(18 U.S.C. §2721 (b) (14))

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).

MV-15C (6/13)

PAGE 2 OF 2

New York State Department of Motor Vehicles

LIST OF PERMISSIBLE USES

DRIVER PRIVACY PROTECTION ACT