CRD 93 (04/13/2020)
Check one or more boxes to indicate your involvement in the crash:
I was a DRIVER. I was a PASSENGER.
I legally REPRESENT a person injured or involved in the crash. I was injured in the crash or as a result thereof (ex: injured pedestrian).
I am the parent or legal guardian of a minor injured or killed in the crash. I am the owner of a vehicle/property involved in the crash.
I am the personal representative (guardian, executor, next of kin, etc.) of a person injured or killed in the crash.
I am an authorized representative of any insurance carrier reasonably anticipating exposure to civil liability as a consequence of the crash or to which a
person has applied for issuance or renewal of a policy of automobile insurance.
IMPORTANT NOTE: The Department may only release a full crash report in accordance with VA Code § 46.2-380.
CRASH DATE (mm/dd/yyyy)
TIME OF CRASH CRASH LOCATION (highway or street name)
CITY/COUNTY/TOWN WHERE CRASH OCCURRED DRIVER FULL NAME (last, first, mi, suffix) DRIVER LICENSE NUMBER
PASSENGER/PEDESTRIAN FULL NAME (last, first, mi, suffix)
1.
PASSENGER/PEDESTRIAN FULL NAME (last, first, mi, suffix)
2.
PASSENGER/PEDESTRIAN FULL NAME (last, first, mi, suffix)
3.
PASSENGER/PEDESTRIAN FULL NAME (last, first, mi, suffix)
4.
POLICE CRASH REPORT
VEHICLE INFORMATION (Includes vehicle description and registration data) (complete SUBJECT INFORMATION above)
VEHICLE IDENTIFICATION NUMBER (VIN) VEHICLE MAKE VEHICLE YEAR
DRIVING RECORD INFORMATION (Includes license history and conviction data) (complete SUBJECT INFORMATION above)
An authorization from the subject is required for employers and others not authorized by Virginia code. I authorize the Department of Motor Vehicles to
furnish, for this one time only, information pertaining to my driving record to the requester identified above.
or
SUBJECT DRIVER LICENSE NUMBER SUBJECT BIRTH DATE (mm/dd/yyyy)
DATE (mm/dd/yyyy)SUBJECT SIGNATURE
REASON FOR REQUEST (Check one)
Insurance Employment, School, or Military
Member/Applicant/Volunteer
Personal Use, Court, or Attorney TNC
Check one or more boxes below to indicate the type of information you wish to receive. All data fields must be completed for Driving Record Information, Vehicle
Information and Decedent Photo Requests. For Police Crash Reports provide as much information as possible.
INFORMATION REQUESTED
SUBJECT INFORMATION
If you are requesting driving record information, the subject will be the person you are requesting information on. If you are requesting vehicle information, the
subject will be the vehicle owner (if available).
SUBJECT FULL NAME (last, first, mi, suffix)
ZIP CODESTATECITY
STREET ADDRESS
CHECK TO INDICATE SUBJECT NAME AND ADDRESS IS THE SAME AS THE REQUESTER ABOVE.
Purpose: Use this form to request information from DMV records.
Instructions: Type or print clearly.
REQUESTER INFORMATION
REQUESTER FULL NAME (last, first, mi, suffix)
ORGANIZATIONAL AFFILIATION (if any)
STREET ADDRESS
TELEPHONE NUMBER
FEDERAL TAX ID OR SOCIAL SECURITY NUMBER*
USE AGREEMENT NUMBER (if applicable)
ACCESS CODE (if applicable)
CITY
STATE ZIP CODE
REASON FOR REQUEST (be specific) (attach additional sheets if necessary)
INFORMATION REQUEST
TNC CERTIFICATE NUMBER (if applicable)
* In accordance with Virginia Code §§2.2-803, 2.2-4807, and 58.1-520 et seq., the State Comptroller requires that the information requested on this application,
including your social security number, be collected for debt set off collection purposes.
