Fillable Printable Form MV-15DS - Data Sharing Agreement - New York

Form MV-15DS - Data Sharing Agreement - New York

MV-15DS (7/15)

www.dmv.ny.gov

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DATA SHARING AGREEMENT

_____________________________________________ (Applicant) requests the following information from the records

of the New York State Department of Motor Vehicles (DMV). DMV agrees to provide such data under the following terms

and conditions.

The information/data elements to be provided are:

This Form Agreement (Form MV-15DS) must be reviewed and approved by both the Contract

Administration Unit and Legal Bureau of the New York State Department of Motor Vehicles (DMV) before

it is signed by the

Applicant

. This Agreement shall not be binding upon DMV until it is executed by an

authorized DMV signatory. Please contact Contract Administration for the identity of the person who is

authorized to execute this Agreement on behalf of DMV.

2. If you share personal information from DMV with an applicant outside your organization, you will collect from that

applicant an agreement identifying the applicant 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 applicant. You will make the agreement available to DMV for audit purposes.

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

4. 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.

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

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

7. 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.

8.This agreement is not transferable.

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MV-15DS (7/15)

1.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.

Applicant’s Address:__________________________________________________________________________

City: __________________________________________________ State: _______ Zip Code:______________

Contact Person:______________________________________________________________________________

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

Email Address: _____________________________________________________________________________

MV-15DS (7/15)

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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.)

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.

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).

MV-15DS (7/15)

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THIS AGREEMENT SHALL NOT BE BINDING UPON DMV UNTIL IT IS

EXECUTED BY AN AUTHORIZED DMV SIGNATORY

IN WITNESS WHEREOF, the undersigned do hereby execute this Agreement by their duly authorized agents.

By,_______________________________________________________________________________(Applicant Name)

New York State Department of Motor Vehicles

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

(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 this Data

Sharing Agreement.

Signature of Applicant: ____________________________________________________ Date:________________

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By,

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Date:

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Title

Please Sign Here

(mm/dd/yyyy)

Date:

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Title

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