Fillable DVS RECORD REQUEST MINNESOTA DEPARTMENT OF PUBLIC SAFETY (Minnesota)

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DVS RECORD REQUEST MINNESOTA DEPARTMENT OF PUBLIC SAFETY (Minnesota)

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PS2502A-23 (10/2019)
445 Minnesota Street,Saint Paul, MN 55101-5161
Phone: (651) 296-2940 TTY: (651) 282-6555
dvs.dps.mn.gov
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
DVS RECORD REQUEST
Non-Certified Copy (5-year History - Convictions only)
Certified Copy
- - - -
Minnesota DL/ID Number:
Driver's Name: Last, First, Middle Date of Birth:
Specific details about driving record request:
Check all that apply. For multiple records, please attach a multiple record supplement to this request form.
B. Motor Vehicle Record Request
Certified Copy + Letter to show the date the driver's license was
originally issued
Payment made out to
Driver & Vehicle
Services
Requester
IS subject
of data
Requester is
NOT subject
of data
Non-Certified Copy
(5 year history)
$9.00 $9.50
Certified Copy $10.00 $10.50
Certified Copy +
License Issuance
Date Letter
$11.00 $11.50
Mail requests to:
Driver and Vehicle Services
Records Unit
445 Minnesota St., Suite 161
St. Paul, MN 55101-5161
Page 1 of 4
A. Driving Record Request:
Vehicle Year & Make: Minn. License Plate #: Vehicle Identification Number:
Title History
Certified Motor Vehicle Record
Motor Vehicle Record
Specific details about motor vehicle request:
Payment made out to
Driver & Vehicle
Services
Requester
IS subject
of data
Requester is
NOT subject
of data
Non-Certified Copy $9.00 $9.50
Certified Copy $10.00 $10.50
Vehicle Title History
$1.00 per printed page, in
addition to the record
fee.
Payment must accompany request - Please make check or money order out to: Driver & Vehicle Services.
o Payments must be made in U.S. dollar amounts.
o Please DO NOT send cash.
o If mailing in: Requester is required to include a legible copy of driver license, government issued
identification card, or notarized signature.
o For a driving record, complete Section A.
o For a motor vehicle record, complete Section B.
o All requestors must complete Section C
o If you are not the subject of the record being requested you must complete Section D by initialling the appropriate
permissible use.
Please Check One Box:
I am requesting a copy of my own record. - Proceed to fill out section A or B and section C.
I am requesting a copy of the record of another person, and I have attached their written consent.
Other - for all other record requests, you must initial at least one permissible use in Section D and complete the additional
required information.
Print Form
PS2502A-23 (10/2019)
Other Photo Identification _________________________
Remarks/Paid Stamp Fee Charged
Page 2 of 4
Notary Information
(If applicable)
Subscribed and sworn before me this ______, day of __________________________, _________.
My Commission expires / /
(Seal)
Date:
The Driver Privacy Protection Act (DPPA) is enforced by the U.S. Department of Justice, which may seek civil and criminal penalties for improperly
obtaining, disclosing or using personal information from a motor vehicle record for a purpose not permitted by the DPPA. In addition, private citizens
may also seek civil damages in Federal Court.
Printed Name of Requester:
Daytime Phone:
Certification I (we) certify that the information and statements on this request are true and correct, comply with the provisions of the Federal Driver's
Privacy Protection Act and understand that the willful, unauthorized disclosure of information obtained from these records for a purpose other than
stated on this request, or the sale or other distribution of the information to a person or organization not disclosed in this request may result in penalties
imposed under Title 18 U.S.C. Section 2724.
Remember to attach a photocopy of the requester's driver license, government-issued identification card, or signature must be
notarized if submitting by mail.
Date:
C. Certification
Email Address:
Mailing Address to Send Record:
Street Address: City:
State: Zip:
DVS Records Request
Signature of Requester/Representative: X
Notary Public Signature
Requester's
Signature
Access to Driver’s License and Motor Vehicle records is governed by:
• Minnesota Statutes, chapters 168.346; 171.12 subd. 7; and 171.12 subd. 7a • United States code title 18, sections 2721-2725 and
Minn. Statute, Chapter 13 • Personal information is classified as private data.
The Department in accordance with Minnesota Statutes, chapter 138.17, will retain this record request.
If you require the return of your request with the record, send the original
request and a duplicate. The copy will be returned.
$
Driver's License or ID Number _________________________
Proof of Requester's Identification
DVS USE ONLY
Record will not be emailed. This is for contact purposes only.
Printed Name of Business:
Name or Business Name:
PS2502A-23 (10/2019)
DVS Records Request
Page 3 of 4
D. Requester's Information - Please select one:
PERMISSIBLE USES OF MOTOR VEHICLE DATA AS PROVIDED IN UNITED STATES CODE, TITLE 18, SECTION 2721
You must tell us why you want the records you are requesting. Sign your initials next to each use under which you claim
access. Driver and Vehicle Services reserves the right to request such additional information as may be necessary to determine
whether you qualify for access.
Authorization:
The requestor is an employee of a federal, state, or local government agency, or a private person acting on behalf of a federal,
state, or local government agency, and the records will be used to carry out the official functions of such federal, state, or local
government agency. (Please attach proof of Requestor's authority to act on behalf of a government agency.)
The records will be used in connection with a civil, criminal, administrative, or arbitral proceeding in federal, state, or local court or
agency or before a 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.
Requestor is (check one):
Name of court:
Name of case or matter:
Case number:
Name of court, agency, or self-regulatory body:
Name of case or matter:
Case/matter number:
Name of involved parties:
Expected forum:
Date of occurrence:
4.
other (attach explanation) attorney represented litigant pro se litigant
Name of agency: Name of agency's contact:
Telephone number of contact:
Email address of contact:
1.
2.
The records will be used 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. (A written explanation detailing the reasons you contend that you qualify for access under this category
must be attached to this Agreement.)
The records will be used in the normal course of business by a legitimate business or its agents, employees, or contractors but only
(i) to verify the accuracy of personal information submitted by the individual to the business or its agents, employees, or contractors,
and (ii) if such information as so submitted is not correct or is no longer correct, to obtain the correct information, but only for the
purpose of preventing fraud by, pursuing legal remedies against, or recovering on a debt or security interest against, the individual. If acting
as agent of lienholder, must submit proof of contract with lienholder.
Name of business: Business tax ID number: Name of business's contact:
Email address of contact:
3.
The records will be used in research activities and for use in producing statistical reports, but the personal information in the records
will not be published, re-disclosed, or used to contact the individual. (A written explanation detailing the reasons you contend that
you qualify for access under this category must be attached to this Agreement.)
5.
The requestor is an agent, employee, or contractor of an insurer or insurance support organization, and the record will be used in
connection with claims investigation activities, anti-fraud activities, rating, or underwriting. (Please attach proof of the Requestor's
status.)
Email address of contact:
6.
Name of insurer or support organization's contact: Name of insurer or insurance support organization:
Telephone number of contact:
Telephone number of contact:
Telephone number of contact:
The records will be used to provide notice to owners (including lienholders) of towed or impounded vehicles.
7.
Email address of contact: Name of company's contact:
Minnesota License Number: Name of towing company:
The requester is an attorney and the records will be used to title a manufactured home in accordance with the process defined in
Minnesota Statute § 168A.143.
PS2502A-23 (10/2019)
The records will be used in connection with the operation of a private toll transportation facility.
Page 4 of 4
DVS Records Request
The requestor is an employer or its agent or insurer and the records will be used to obtain or verify information relating to a holder
of a commercial driver's license that is required under 49 U.S.C. Chapter 313. (Please attach proof of the Requestor's status.)
9.
Email address of contact:
Name of employer's contact: Name of employer:
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.
11.
The requestor is a licensed private investigative agency or licensed security service, and the Requestor will use the record for a
permitted purpose. (Photocopy of Minnesota Private Investigator's License must be attached. Also, if you claim access under this paragraph,
you must initial another paragraph indicating the permitted use, and you must provide any applicable attachments required therein.)
8.
Name of agency or service's contact:
Minnesota license number:
Email address of contact:
Name of private investigative agency or licensed security service:
10.
Email address of contact: Name of facility's contact:
Licensing entity and number: Name of private toll transportation facility:
12.
For bulk distribution surveys, marketing, or solicitation if the state has obtained express consent of the person whom such personal
information pertains.
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.
List specific statutory authorization:
13.
Any additional specifics tied to this request or permissible use to obtain the requested information:
Telephone number of contact:
Telephone number of contact:
Telephone number of contact:
PERMISSIBLE USES OF MOTOR VEHICLE DATA AS PROVIDED IN UNITED STATES CODE, TITLE 18, SECTION 2721
You must tell us why you want the records you are requesting. Sign your initials next to each use under which you claim
access. Driver and Vehicle Services reserves the right to request such additional information as may be necessary to determine
whether you qualify for access.
Authorization:
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DVS RECORD REQUEST MINNESOTA DEPARTMENT OF PUBLIC SAFETY (Minnesota)

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Completed 30 July 2020

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