Emergency Communications
Government Center
1101 Carmichael Road | Hudson WI 54016
Telephone: 715-386-4701 | Fax: 715-386-9329
www.sccwi.gov
FEDERAL DRIVER PRIVACY
PROTECTION ACT PERMISSIBLE USES FORM
Based upon the Federal Driver's Privacy Protection Act, this Request must be completed before
information containing personally identifiable information in the Police Report can be released
without redaction. Knowledge of what access and uses are permitted under the listed Federal Act
is the
responsibility of the Requester.
SECTION I. REQUESTER INFORMATION:
Name of Person Completing Form: ___________________________________________________________
Firm/Corporation: ___________________________________________________________________________________
Phone Number: ___________________________________________________________________________
Street Address: ______________________________________________________________________________________
SECTION II. RECORD INFORMATION SHEET
Date of Accident/Incident: __________________________________________________________________________
Location of Accident/Incident: ______________________________________________________________________
Party Name to the Accident/Incident: ______________________________________________________________
SECTION III. AUTHORIZATION
The Driver's Privacy Protection Act is enforced by the United States Department of Justice, which may
seek civil and criminal penalties for improperly obtaining, disclosing, or using personal information
from
an accident report or other police record, or the information was acquired through the
Wisconsin
Department of Transportation System and it is determined that these records are used
for purposes other
than as stated in this Request.
I/We are authorized under the Federal Driver's Privacy Protection Act to obtain the identified
accident/incident report and personal information based upon the following (mark all applicable
boxes):
1. Authorized for use, if Requester has obtained the written and notarized consent from the
person about whom the information pertains.
I am requesting a copy of my own record.
I am a parent or legal guardian of a minor child and I am requesting a copy of his/her
record.
I am requesting the record of another person and have attached his or her written
and notarized consent.
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2. For use in connection with matters of a 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 to carry out the purposes of the
Automobile Information
Disclosure Act, the Anti-Car Theft Act of 1992 and the Clean Air
Act.
3. A government agency (Federal, State, local or tribal) or employed by such, for the purposes
of the government agency to carry out its official functions.
4. A Federal, State, Circuit, local or tribal court, or employed by such, for the purposes of
the
court to carry out its official functions.
5. A Wisconsin or out-of-state law enforcement agency, or employed by such, for the
purpose
of the law enforcement agency to carry out its functions.
6. Authorized representative, agent, contractor, or employed by such, of a legitimate
business
and the vehicle/driving record being requested will be used for normal course
of business, but
only to:
a.
Verify accuracy of the personal information;
b.
Obtain correct information, but only for purposes of preventing fraud, pursuing legal
remedies, or collecting a debt.
7. Authorized for use in connection with any civil, criminal, administrative, or arbitral
proceedings in any federal, state, circuit, local, or tribal 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, circuit, local, or tribal court.
Client's Name: __________________________________________________________________________
8. Authorized for use in research activities and producing statistical reports, as long as the
personal information is not published, redisclosed, or used to contact individuals.
Date Range:___________________________
Kind/nature: ___________________________________
9. Authorized representative, agent, contractor, or employed by such, of an insurer, insurance
support organization or self-insured entity and the vehicle/driving record(s) being
requested
will be used only in connection with the following:
a. Claims investigation;
b. Anti-fraud activities;
c. Rating or underwriting. Client’s Name: __________________________________________________
10. Authorized for use in providing notice to the owners of towed or impounded vehicles.
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11. Authorized representative or owner of a licensed private investigative agency or licensed
security service and the vehicle/driving record is being requested for the use of
purposes permitted under the Federal Driver's Privacy Protection Act.
12. Authorized as an employer, or its agent or insurer for use in obtaining or verifying
information relating to a holder of a commercial driver license (CDL).
13. Authorized representative or owner of a private toll transportation facility for use in the
operation of the facility.
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 civil and criminal penalties imposed under
Title 18 U.S.C. Section 2724.
X ________________________________________________ ______________________
(Requester Signature) (Date Signed)
For Agency Use Only
Report# ____________________
Date of Request ______________