sit us at www.NJMVC.gov
New Jersey is an Equal Opportunity Employer
DO-11A (R 10/19) Page 2 of 4
ASE READ THE BELOW SECTION OF THE NEW JERSEY DRIVER PRIVACY PROTECTION ACT, INITIAL NEXT TO THE
PERMITTED USE(S) THAT APPLY TO YOUR SPECIFIC USE OF THE MVC RECORDS. THEN PROVIDE A WRITTEN EXPLANATION
OF THE REASON FOR YOUR REQUEST AND INTENDED USE OF THE INFORMATION.
USES PERMITTED BY N.J.S.A. 39:2-3.4(c)
______ 1. For use by any government agency including any court or law enforcement agency 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.
If acting on behalf of a government agency, please provide proof of retention.
______ 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 the removal of non-owner records form the original owner records of
motor vehicle manufacturers.
Please include the documentation supporting your request if the information is to be used for motor vehicle emissions, recalls or
______ 3. 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 agents, employees or
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
Please include a copy of the individual release consent form; a contract; a tow bill; or a repair bill from the repair shop with the
person in question.
______ 4. 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-regulating body, including 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.
Please include the Docket number and a letter from the client confirming that you have been retained. Please provide an explanation
if no docket number has been assigned. If no Docket number is available, please submit the case file number on Attorney letter
head and include a copy of the accident report.
______ 5. For use in educational initiatives, research activities, and for use in producing statistical reports, so long as the personal
information is not published, redisclosed, or used to contact individuals and, in the case of educational initiatives, only to organ
procurement organizations as aggregated, non-identifying information.
Please include a description of the initiative or research on official letterhead
______ 6. 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.
Please include supporting documents for intended use i.e. declaration page.
______ 7. For use in providing notice to the owners of towed or impounded vehicles.
Please include proof of authorization to tow or impound vehicles.
______ 8. 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. App. §2710 et seq.
Please include a copy of an individual release consent form, a copy of the insurance policy, and a copy of the agreement if done on
behalf of a client.
______ 9. For use in connection with the operation of private toll transportation facilities.
If your request does not fall under one of the above reasons:
______ 10. For use by any requestor, if the requestor demonstrates it has obtained the notarized written consent of the individual to the
*Please note: If you selected number 10, a “Notarized Authorization to Release Personal Motor Vehicle
Information” (Form BGS/DO-21A) must be submitted and will not be accepted unless it is acknowledged by a
Notary Public or Attorney at Law.
SECTION C – Purpose for the Request (required ONLY when requesting another’s record)