Fillable TENNESSEE DEPARTMENT OF REVENUE Vehicle Information Request and (State of Tennessee)

Fill Online, Printable, Fillable, Blank TENNESSEE DEPARTMENT OF REVENUE Vehicle Information Request and (State of Tennessee) Form

Use Fill to complete blank online STATE OF TENNESSEE (TN) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

TENNESSEE DEPARTMENT OF REVENUE Vehicle Information Request and (State of Tennessee)

On average this form takes 6 minutes to complete

The TENNESSEE DEPARTMENT OF REVENUE Vehicle Information Request and (State of Tennessee) form is 3 pages long and contains:

  • 1 signature
  • 17 check-boxes
  • 13 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State of Tennessee

BROWSE STATE OF TENNESSEE (TN) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
This request must be completed before motor vehicle information can be obtained from the Tennessee Department of Revenue. Knowledge of
what access and uses are permitted under the listed State and Federal Acts is the responsibility of the requester. This Request and Certification
will expire at the end of the quarter in which it is received by the Department.
SECTION C. Authorization: Please check the statement(s) below that describe the purpose(s) for which you will use the requested
information.
I am authorized under the Federal Driver's Privacy Protection Act, 18 U.S.C. §§ 2721-2725 (2012), and the Tennessee Uniform Motor
Vehicle Records Disclosure Act, TENN. CODE ANN. §§ 55-25-101 through -112 (2012 & Supp. 2013) to obtain the identified records and
personal information for the following use(s):
Use by a 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. TENN. CODE ANN. § 55-25-107(b)(1). Your request for
information must be accompanied by a statement on agency letterhead verifying employment status. TENN. CODE ANN. § 55-25-107(b)(1).
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. TENN.
CODE ANN. § 55-25-107(b)(2).
SECTION B. Vehicle Information Requested and Fee
I request that the vehicle information be provided during this quarter:
Once Weekly Every Two Weeks Monthly
Fee:
The Department of Revenue may charge a fee not to exceed one dollar ($1.00) for each motor vehicle record requested. TENN. CODE
ANN. § 55-2-106. For large volume requests, the fee will be based upon costs of labor and information technology incurred by the State
in completion of this request. The Department will notify the requester of the estimated fee and preferred payment method.
SECTION A. Requester Information
Name of Business or Governmental Entity:____________________________________________________________________________
Name and Title of Person Submitting the Request:______________________________________________________________________
Street Address ________________________________________ City, State, Zip _______________________________________
E-mail Address ________________________________________ Telephone No. _______________________________________
Mailing Address _______________________________________________________________________________________________
(if different from Street Address)
A detailed description of the nature of the requester’s business and the intended use of the requested information for each
exception selected must be attached to this form, on company or agency letterhead.
TENNESSEE DEPARTMENT OF REVENUE
Vehicle Information Request and Certification
(Large Volume)
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 the personal information submitted by the individual to the business or its agents, employees,
or contractors, T
ENN. CODE ANN. § 55-25-107(b)(3)(A); or
b. To obtain correct information if the above is not correct or no longer correct, but only for purposes of preventing fraud,
pursuing legal remedies, or recovering on a debt or security interest against the individual. T
ENN. CODE ANN. § 55-25-
107(b)(3)(B).
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. T
ENN. CODE ANN. § 55-25-107(b)(4).
Use in research activities, and for use in producing statistical reports, so long as the personal information is not published, redisclosed, or
used to contact individuals. TENN. CODE ANN. § 55-25-107(b)(5).
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. TENN. CODE ANN. § 55-25-107(b)(6).
Use in providing notice to owners of towed or impounded vehicles. TENN. CODE ANN. § 55-25-107(b)(7).
Use by any licensed private investigative agency or licensed security service for any exempted use listed. TENN. CODE ANN. § 55-25-
107(b)(8). The requester must attach a copy of the applicable license.
Use by any employer or its agent or insurer to obtain or verify information relating to a holder of a commercial driver license that is
required under 49 U.S.C. § 31301, et seq. TENN. CODE ANN. § 55-25-107(b)(9).
Use in connection with the operation of private toll transportation facilities. TENN. CODE ANN. § 55-25-107(b)(10).
Use in bulk distribution for surveys, marketing, or solicitation if the State has obtained the express consent of the person to whom the
personal information pertains. TENN. CODE ANN. § 55-25-107(b)(12). The requester must attach a copy of the written consents to this
application.
Use by any requester, if the requester provides written consent of each person to whom the personal information pertains. TENN. CODE
ANN. §§ 55-25-106, -107(b)(13). The requester must attach a copy of the written consents to this application.
Use as specifically authorized under the law of the State, if that use is related to the operation of a motor vehicle or public safety. TENN.
CODE ANN. § 55-25-107(b)(14). The law specifically authorizing the use of the information is TENN. CODE ANN. § _________________.
SECTION D. Redisclosure
A recipient of motor vehicle records may only resell or redisclose the information disclosed by the Department for uses permitted under the
Federal Driver's Privacy Protection Act, 18 U.S.C. §§ 2721-2725 and the Tennessee Uniform Motor Vehicle Records Disclosure Act,
T
ENN. CODE ANN. §§ 55-25-101 through -112.
A recipient of motor vehicle records shall make and keep for five years, records identifying each person to whom the recipient redisclosed the
information and the permitted purpose for which the information was redisclosed. Such records shall be made available upon request for
inspection and copying by a representative of the Department of Revenue or Department of Safety. T
ENN. CODE ANN. § 55-25-107(c).
SECTION E. Legal Proceedings
List all legal proceedings involving the Federal Driver's Privacy Protection Act, the Tennessee Uniform Motor Vehicle Records Disclosure
Act, or other comparable state law, to which the requester or an affiliate of the requester is or has been a party, and the outcome of each
proceeding. Detailed information may be attached. If neither the requester nor any affiliate of the requester has been a party in a legal
proceeding indicate this by placing NONE below.
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
____________________________________________________________________________________________________________
SECTION F. Certification
If requesting information on behalf of an organization, I certify that I have authority to submit this application on behalf of the organization. I
certify that the information and statements on this request are true and correct and comply with the provisions of the Federal Driver's Privacy
Protection Act, 18 U.S.C. §§ 2721-2725 and the Tennessee Uniform Motor Vehicle Records Disclosure Act, TENN. CODE ANN. §§ 55-25-
101 through -112. I 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 18 U.S.C. § 2724. I further understand that misrepresentation of my identity or the making of false statements on this
application constitutes a Class C misdemeanor, punishable by a fine not to exceed $1,000. T
ENN. CODE ANN. § 55-25-112. I further certify that I
understand and will comply with the recordkeeping requirements under T
ENN. CODE ANN. § 55-25-107(c) and other applicable laws and will
fully cooperate with the State of Tennessee in any audit or examination of use of the motor vehicle information obtained through this request.
If requesting information on behalf of an organization, I certify that the organization is in good standing and is registered to do business in the
State of Tennessee, if required to do so under applicable law.
The requester shall indemnify the Department of Revenue for any liability or penalty imposed under state or federal law due to the unauthorized
use of information obtained through this request, whether by the requester, its contractors, its employees, or parties to whom it resells or
rediscloses such information, and that this obligation shall continue beyond the expiration or completion of the request. The requester hereby
consents to the jurisdiction of the State of Tennessee.
I understand that this request, but not the obligations agreed to thereunder, will expire at the end of the quarter in which it is received by the
Department of Revenue and that I must submit a new certification to receive motor vehicle information each quarter.
________________________________________ _______________________________________ _____________________
Signature Driver’s License Number State Date Signed
Mail to: State of Tennessee, Department of Revenue
Vehicle Services Division
500 Deaderick Street
Nashville, TN 37242
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

TENNESSEE DEPARTMENT OF REVENUE Vehicle Information Request and (State of Tennessee)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 4 August 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document