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.
( )
CRD 93 (04/13/2020)
REQUESTER SIGNATURE DATE (mm/dd/yyyy)
I understand that it is unlawful to use information provided by DMV for any purpose other than the one stated. I certify that the information I have requested with
this form will be used only for the stated purpose and that any personal information I receive will not be used for the predominant purpose of solicitation of
perspective clients.
I further certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the
information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that
knowingly making a false statement or representation on this form is a criminal violation.
I agree that the information I obtain in response to my request is considered privileged and confidential. I agree that such information is subject to the restrictions
upon use and dissemination imposed by (1) the Federal Drivers Privacy Protection Act (18 USC § 2721 et seq.), (2) the Government Data Collection and
Dissemination Practices Act (Va. Code § 2.2-3800 et seq.), (3) the provisions of Va. Code §§ 46.2-208 through 210, 46.2.212, and 58.1-3, and (4) any successor
rules, regulations, or guidelines adopted by DMV with regard to disclosure or dissemination of any information obtained from DMV records or files, and I agree to
comply with such restrictions and understand that any violation may result in damages, civil penalties, criminal penalties or other relief permitted pursuant to
Virginia law.
For volunteer organizations identified in Va. Code § 46.2-208(B), I also certify that the subject of the information being requested is a member of, applicant for
membership in or applicant to be a volunteer with my organization.
CERTIFICATION
PAYMENT METHODS
ENTER CHECK AMOUNT
CHECK
Made payable to DMV
MONEY ORDER
Made payable to DMV
ENTER MONEY ORDER AMOUNT
If you are mailing this request, DMV can only accept check or money order via mail.
Proof of Requester's Identification
Valid Driver's License Number ______________________
Request on Organization Letterhead Stationery
Business Card from Organization
Other _________________________________
If referred to Headquarters to Fill Request, Complete:
CSR Name __________________________________________
CSC Name (not CSC number) ___________________________
Law Enforcement Badge Number ________________
DMV CUSTOMER SERVICE CENTER USE ONLY
Other Photo Identification _________________________
Remarks/CSR Stamp Fee Charged
$
Proof of Requester's Organization Affiliation
Requester's relationship to decedent (check one):
DECEDENT PHOTO REQUEST (requester may need to provide proof of death, i.e. copy of death certificate, executor papers, etc.)
DECEDENT FULL NAME (last, first, mi, suffix) DECEDENT DMV CUSTOMER NUMBER
Administrator
Executor
DECEDENT BIRTH DATE (mm/dd/yyyy)
INFORMATION REQUESTED (continued)
OTHER INFORMATION (Be specific)
CUSTOMER RECORDS FEES
Driving Record ................................... $9.00
Vehicle Record................................... $9.00
Police Crash Report ............................. $8.00
Decedent Photo... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . $9.00
Driver/Vehicle Application ...................... $9.00
Supporting Documents (per page) ................ $3.00
Motor Carrier Overweight Citation Record ....... $8.00
Travel Emergency Photo Verification ... .. .. .. .. .. $9.00
Record Certification Fee (additional).............. $5.00
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