Fillable Printable Form MV-15D - Motor Vehicle Record Search Account Application - New York

Form MV-15D - Motor Vehicle Record Search Account Application - New York

Organization: ______________________________________________________________________________________

Address: __________________________________________________________________________________________

City: __________________________________________________ State:_________ Zip Code:____________________

Telephone: _______ - _______ - __________ Ext. ____________ Fax: _______ - _______- __________

Email Address: ____________________________________________________________________________________

Federal Employer ID Number:

Please describe in detail how you plan to use the information from searches of DMV’s records:

If DMV has ever terminated a search account held by you, your organization, or any principal, agent, officer or

employee associated with your organization, please provide the account number(s):

_________________________________________________________________________________________________

MOTOR VEHICLE RECORD

SEARCH ACCOUNT APPLICATION

u Before you begin, please review the Terms of Service on page 3.

u If you are opening a new account for a commercial or not-for-profit organization, attach an opening deposit. The

deposit amount should fund your estimated usage for two months. Electronic searches are $7 each. Mail order searches

are $10 or more, depending on what kinds of certified documents you request. Please make your check or money order

payable to “Commissioner of Motor Vehicles”.

u If you represent a commercial or not-for-profit organization (including volunteer fire companies and volunteer

ambulance services),

include a certified copy of your business certificate.

u Send the form to: DATA SERVICES - NEW SEARCH ACCOUNT

NYS DEPARTMENT OF MOTOR VEHICLES

6 EMPIRE STATE PLAZA

ALBANY NY 12228

Please mark one of the following boxes to indicate which service you are requesting:

o Open new account

o Update information for an existing account. DMV will need your account number to process any changes.

ACCOUNT #:_____________________________

MV-15D (7/15)

www.dmv.ny.gov

PAGE 1 OF 4

http://dmv.ny.gov/dial-in

Email: [email protected]

ACCOUNT INFORMATION

(Please Print or Type)

Applicant: ________________________________________________________________________________________

Applicant’s Driver License Number: _________ - _________ - _________ State/Province: ______________________

and you will be using the information obtained for a public purpose, complete the Fee Exemption Certification on

page 4 to claim the exemption from search fees under Section 202 of the New York State Vehicle and Traffic Law.

You must also provide evidence of your government employment or your affiliation with the exempt

organization, such as a pay stub or an official letter from the organization.

u If you are opening a new account for a:

u government organization;

u volunteer fire company;

u volunteer ambulance service;

u legal aid bureau or society or other private

entity when acting pursuant to Section 722 of

the New York State County Law;

(DO NOT GIVE P.O. BOX)

MV-15D (7/15)

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

Recipient hereby certifies that the information provided hereunder by DMV shall be used solely for the following purpose(s).

(Recipient must check all that apply)

1. ___ Use by any government agency including any court or law enforcement agency, in carrying out its functions. (18 U.S.C. §2721 (b)(14))

2. ___ 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))

3. ___ Use in matters of motor vehicle or driver safety. (18 U.S.C. §272 (b)(2))

4. ___ Use in matters of motor vehicle theft. (18 U.S.C. §2721 (b)(2))

5. ___ Use in matters of motor vehicle emissions. (18 U.S.C. §2721 (b)(2))

6. ___ Use in matters of motor vehicle product alterations, recalls or advisories. (18 U.S.C. §2721 (b)(2))

7. ___ Use in performance monitoring of motor vehicles, motor vehicle parts and dealers. (18 U.S.C. §2721 (b)(2))

8. ___ Use in motor vehicle market research activities, including survey research (18 U.S.C. §2721 (b)(2))

9. ___ Use in removal of non-owner records from the original owner records of motor vehicle manufacturers. (18 U.S.C. §2721 (b)(2))

10. ___ 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; (18 U.S.C. §2721 (b)(3)(A)) 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. (18 U.S.C. §2721 (b)(3)(B))

11. ___ 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))

12. ___ 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))

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

14. ___ Use by an employer, its agent or insurer to obtain information relating to the holder of a commercial driver license required under

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

15. ___ Use in the operation of private toll transportation facilities. (18 U.S.C. §2721 (b)(10))

16. ___ 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-25GC)(18 U.S.C. §2721 (b)(13))

17. ___ Use required under NYS Vehicle and Traffic Law, Article 19-A — Special Requirements for Bus Drivers. (18 U.S.C. §2721 (b)(14))

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

(18 U.S.C. §2721 (b)(14))

19. ___ 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).

CERTIFICATION OF PERMISSIBLE USES

MV-15D (7/15)

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1. You will perform searches of DMV records only when one of the permissible uses that you initialed on page 2

arises. You agree not to perform searches of DMV records for the purposes described in 18 USC Sec 2721(b)(5),

(11), and/or (12). Under the New York State Information Security Breach and Notification Act, DMV is

required to notify individuals if their records are accessed for unauthorized purposes.

2. You will notify DMV in writing, within 30 days, if there is any change in the information you have

provided in this application. You will file a replacement for this application within 60 days of any

request by DMV to do so.

3. You will maintain business records documenting the purpose of each search and identifying the individual who

performed the search. You will maintain each record FOR FIVE YEARS after the date of your search. The records

must be available to DMV, upon request, for audit purposes. At DMV’s direction, you will forward the records to

DMV or you will make the records available for inspection at your place of business. The records must be

organized to permit retrieval by the name, license number, plate number or VIN for which you searched. If you do

not maintain an office location within New York State, you may be asked to forward all records requested to a

place and location designated by the Department. The location where you will keep records of searches is:

Address: ____________________________________________________________________________________

City: ___________________________________________ State: _______ Zip Code:______________________

Contact Person: ______________________________________________________________________________

Telephone: _______ - _______ - _________ Ext. __________ Fax: _______ - _______- _________

Email Address: _____________________________________________________________________________

4. If you share personal information from DMV with a recipient outside your organization, you will collect from that

recipient an agreement identifying the recipient and specifying their DPPA Permissible Use for the information.

You will retain the agreement FOR FIVE YEARS after the date when you last shared DMV records information

with the recipient. You will make the agreement available to DMV for audit purposes.

5. You will not represent yourself as an agent or employee of the DMV.

6. You will defend, indemnify and hold harmless the DMV and its employees or agents from all claims, actions,

damages, or losses, including the cost of any notifications required under the New York State Information Security

Breach and Notification Act, arising from your negligent, improper, or unauthorized use or dissemination of

information contained in DMV records.

7. New York State will not be responsible for any omissions or errors in the information furnished to you.

8. You acknowledge that all records of searches placed by you are public records, and may be made available to any party.

9. The DMV reserves the right to terminate access to your account at anytime, in its sole discretion, and without

advance notice. Reasons for termination include but are not limited to: false statements made by you; concealment

of material facts in connection with this application; and violation of any of the terms of service.

10. This agreement is not transferable.

reset/clear

MV-15D (7/15)

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TO BE COMPLETED BY NOTARY

STATE OF _____________ }

} ss:

COUNTY OF _____________ }

On the _________ day of _______________ in the year 20____ before me, the undersigned, a Notary Public in and for

said State, ________________ personally appeared __________________________________, personally known to me

or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the

within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies), and that by

his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted,

executed the instrument.

____________________________________________

Notary

FEE EXEMPTION CERTIFICATION

FOR GOVERNMENT ORGANIZATIONS, VOLUNTEER FIRE COMPANIES,

VOLUNTEER AMBULANCE SERVICES, AND ENTITIES ACTING PURSUANT TO

SECTION 722 OF THE NEW YORK STATE COUNTY LAW ONLY

Section 202 of the New York State Vehicle and Traffic Law exempts government organizations, volunteer fire companies,

and volunteer ambulance services from fees for searches and documents to be used for a public purpose, and also

exempts legal aid bureaus and societies and other private entities from such fees when acting pursuant to Section 722 of

the New York State County Law. I certify that my organization qualifies for this exemption, and that I will use this

account only for qualified fee-exempt purposes.

Signature of Applicant: ____________________________________________________ Date: ________________

(Sign in the presence of a notary)

ACKNOWLEDGEMENT OF TERMS OF SERVICE

I certify that I have read, understood, and will comply with the DPPA, and the Terms of Service for use of the search

account.

Signature of Applicant: ____________________________________________________ Date: ________________