reset/clear
YOU MUST ATTACH A COPY OF YOUR ID.
I certify that I have read the Drivers Privacy Protection Act (18 U.S.C. Sec 2721 et seq.) and will comply fully with the terms of such law. I also agree to defend,
hold harmless and indemnify DMV from all actions brought against DMV, or damages alleged against DMV, for my negligent, improper or unauthorized use or
dissemination of the information provided by the DMV.
I certify that if I receive or have access to records or information from the DMV, I shall not (i) use such records or information for civil immigration purposes
or (ii) disclose such records or information to any agency that primarily enforces immigration law, such as U.S. immigration and customs enforcement and U.S.
customs and border protection, or to any employee or agent of any such agency unless such disclosure is pursuant to a cooperative arrangement between city,
state and federal agencies which does not enforce immigration law and which disclosure is limited to the specific records or information being sought pursuant
to such arrangement. I certify that, in addition to the requirements of 18 USC 2721(c), I shall keep for a period of five years records of all uses and identifying
each person or entity that primarily enforces immigration law that received department records or information from such certifying person or entity. I shall
maintain the records in a manner and form prescribed by the commissioner, and I shall make them available for inspection upon the commissioner’s request.
Signature
Print Name
MV-15 (12/19)
Driver Privacy Protection Act: The Federal Driver’s Privacy Protection Act (DPPA) (18 U.S.C. §2721.et seq.) (“DPPA”) regulates access to Motor
Vehicles records. Recipient hereby certifies that the information provided hereunder by DMV shall be used solely for the following purpose(s).
(Recipient must check all that apply.)
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1. Use in any civil, criminal, administrative, or arbitral proceeding in any court or agency, including the service of process, investigation in
anticipation of litigation, and the execution or enforcement of judgments and orders or pursuant to a court order. (18 U.S.C. §2721 (b)(4))
2. Use by an insurer or insurance support organization or self-insured entity in claims investigations, anti-fraud activities, rating or
underwriting activities. (18 U.S.C. §2721 (b)(6))
3. Use in providing notice to the owners of towed or impounded vehicles. (18 U.S.C. §2721 (b)(7))
4. Use by an employer, its agent or insurer to obtain information relating to the holder of a commercial driver's license required under
Chapter 313 of Title 49 of the U.S.C. (18 U.S.C. §2721 (b)(9))
5. 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 agents, employees, or
contractors; (18 U.S.C. §2721 (b)(3)(A)) and
(B) if such information as so submitted is not correct or is no longer correct, to obtain the 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. (18 U.S.C. §2721 (b)(3)(B))
6. Use required under NYS Vehicle and Traffic Law, Article 19A - Special Requirements for Bus Drivers. (18 U.S.C. §2721 (b)(14))
7. Use required under NYS Vehicle and Traffic Law, Article 19B - Special Requirements for Commercial Motor Carriers.
(18 U.S.C. §2721 (b)(14))
8. Use by any government agency, including any court or law enforcement agency, in carrying out its functions. (18 U.S.C. §2721 (b)(1))
9. Use by any private person or entity acting on behalf of a federal, state, or local agency in carrying out its functions.
(18 U.S.C. §2721 (b)(1))
10. Use in matters of motor vehicle or driver safety. (18 U.S.C. §2721 (b)(2))
11. Use in matters of motor vehicle theft. (18 U.S.C. §2721 (b)(2))
12. Use in matters of motor vehicle emissions. (18 U.S.C. §2721 (b)(2))
13. Use in matters of motor vehicle product alterations, recalls or advisories. (18 U.S.C. §2721 (b)(2))
14. Use in performance monitoring of motor vehicles, motor vehicle parts and dealers. (18 U.S.C. §2721 (b)(2))
15. Use in motor vehicle market research activities, including survey research. (18 U.S.C. §2721 (b)(2))
16. Use in removal of non-owner records from the original owner records of motor vehicle manufacturers. (18 U.S.C. §2721 (b)(2))
17. Use in the operation of private toll transportation facilities. (18 U.S.C. §2721 (b)(10))
18. For use by any requester, if the requester demonstrates it has obtained the written consent of the individual to whom the
information pertains. (May use form MV-15GC). (18 U.S.C. §2721 (b)(13))
19. Use specifically authorized under NYS law, IF such use is related to the operation of a motor vehicle or public safety.
Cite the specific NYS law here: (18 U.S.C. §2721 (b)(14))
20. Use in research activities and in producing statistical reports,
as long as the personal information is not published, disclosed
or used to contact individuals.
(18 U.S.C. §2721 (b)(5))
To knowingly make a false statement or conceal a material fact in this written statement may be punishable as a criminal offense. In addition, anyone who makes
false representation to obtain any personal information from an individual’s Motor Vehicles record is subject to federal criminal fines under the Driver’s Privacy
Protection Act (DPPA).
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PERMISSIBLE USE(S) & CERTIFICATION
PLEASE DO NOT STAPLE
REQUESTOR
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