SECTION C (GOVERNMENT AGENCIES ONLY) Continued
3. A Tennessee or out-of-state law enforcement agency, or employed by such, for the purpose of the law enforcement agency to carry out its
4. Authorized for use in connection with any civil, criminal, administrative, or arbitral proceeding 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.
1. Authorized for use, if the requester demonstrates that they have obtained the written consent from the person about whom the information
pertains. (Written consent must be notarized and presented at the time of this request.)
2. 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 to carry out the
purposes of the Automobile Information Disclosure Act. The National Traffic and Motor Vehicle Safety Act, the Anti-Car Theft Act, and
the Clean Air Act.
3. 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:
Verify accuracy of the personal information submitted by the agency.
b. Obtain correct information, but only for purposes of preventing fraud, pursuing legal remedies, or collecting a debt.
4. 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.
5. 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:
b. Anti-Fraud activities
Rating or Underwriting
6. Authorized for use in providing notice to the owners of towed or impounded vehicles.
7. 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.
8. Authorized representative or owner of a private toll transportation facility for use in the operation of the facility.
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. I assume responsibility for all information released to me as indicated in T.C.A. 55-25-101 through 55-25-112.
Signature Driver License Number State Date Signed
Mail to: State of Tennessee, Department of Revenue
Taxpayer and Vehicle Services Division
44 Vantage Way, Suite 160
Nashville, TN 37243-8050