Fillable Motor Vehicle Private Data Request (Minnesota)

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Motor Vehicle Private Data Request (Minnesota)

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The Motor Vehicle Private Data Request (Minnesota) form is 1 page long and contains:

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Reason for Safety Concern:
Please Check All That Apply:
I am filing this private data request for the safety of my family or myself. I understand that my name and/or residence address will be
classified as private data and will not be released to anyone except, law enforcement agencies, probation and parole agencies, and child
support enforcement as defined by Minn. Stat. 168.346, Subd. 3.
The service of process address I provided is a valid, existing address, and I consent to receive service of process and notices pertaining to
the vehicle at this address. The service of process address will be used in place of the residence address for dissemination in accordance
with the DPPA (see page2).
PS33202MV-1 (04/19)
This form is intended for use by individuals who have a grave concern for their safety or the safety of their family. You are requesting that
your address and or name not be provided to any authorized user.
Return this form by mail to 445 Minnesota Street, Suite 191, St. Paul, MN 55101, email to DVS.DataServices@state.mn.us or in
person to your local deputy registrar office.
Tennessen Warning Notice:
• Driver and Vehicle Services is requesting certain private data and complies with all federal and state laws regarding the
dissemination of motor vehicle data.18 U.S. Code § 2721 and Minn. Stat. § 168.346, Subd. 1
• Your name, date of birth, and address collected on motor vehicle applications is restricted and only released to law enforcement
agencies, probation and parole agencies, and child support enforcement.
• Your name and address are NEVER public data.
• You are not required to provide the information on this form, but DPS cannot classify your address as private data without it.
• A valid service of process address is required. This is the address that will be provided be to any authorized users.
• The service of process address must be different than your Minnesota residence address. Minn. Stat. 168.346, Subd. 3.
Data Privacy Laws: Drivers Privacy Protection Act (DPPA), United States Code, title 18, sections 2721-2725; Minnesota Data Privacy Act,
Minnesota Statutes, Chapter 13; Minnesota Statute 168.346
Motor Vehicle Private Data Request
City/State/ZipResidence Address
Date of Birth
Last Name Middle Name
First Name
General Information
Name: I request that my name be classified as private data on the above motor vehicle record.
Service of Process Address County
City/State/Zip
Date
Signature
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
445 Minnesota Street, Saint Paul, MN 55101
Phone: (651) 297-3298 TTY: (651) 282-6555 Web: dvs.dps.mn.gov
VIN Number
License Plate Number
Motor Vehicle Address: I request that my residence address on the above motor vehicle record be classified as private
data and reflect the valid service of process address below.
For additional vehicles, complete separate forms.
Print Form
PERMISSIBLE USES OF MOTOR VEHICLE DATA AS PROVIDED IN
UNITED STATES CODE, TITLE 18, SECTION 2721
• 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.
• 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.
• 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 agencies, employees, or contractors; and
(B) if such information as so submitted is not correct or is no longer correct, to obtain 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.
• 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.
• 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.
• 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, antifraud activities, rating, or underwriting.
• For use in providing notice to the owners of towed or impounded vehicles.
• For use by any licensed private investigative agency or licensed security service for any purpose permitted under this subsection.
• 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
the Commercial Motor Vehicle Safety Act, 49 U.S.C. §§ 31301-17.
• For use in connection with the operation of private toll transportation facilities.
• 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.
• 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.
• For use by any requester, if the requester demonstrates it has obtained the written consent of the individual to whom the 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.
PS33202MV-1 (04/19)
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Motor Vehicle Private Data Request (Minnesota)

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Completed 23 November 2020

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