Form Mvd-11260 - Confidential Records Release
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1State of New Mexico - Taxation & Revenue Department
MVD-11260
MOTOR VEHICLE DIVISION
REV. 03/01
CONFIDENTIAL RECORDS RELEASE
(Pursuant to Section 66-2-7.1, NMSA 1978)
TYPE OR PRINT PLAINLY (INQUIRIES THAT CANNOT BE READ WILL NOT BE PROCESSED)
Provisions of the New Mexico Motor Vehicle Code make personal information about an individual confidential, and restrict disclosure. This
form authorizes the release of Driver or Vehicle information containing personal information to:
•
an individual, or an individual's authorized representative; or
•
a requestor, if the requestor has obtained the written consent of the individual to whom the information pertains.
Note: For purposes of this Release, the term "personal information" means:
• with respect to vehicle records, the driver license number, date of birth, address, city and state.
• with respect to driver records, the name, address, city, state, social security number, driver license number, date of birth, height,
weight, medical restrictions, image and signature.
REQUESTOR / AUTHORIZED REPRESENTATIVE NAME & ADDRESS
REQUESTOR' S NAME - Company or Individual - (Last, First, MI ):
Requestor's SS # or Employer ID #
Mailing Address (Number & Street):
City, State, Zip Code:
PERSON TO WHOM INFORMATION PERTAINS
NAME (Last, First, MI)
Mo./ Day / Yr. of Birth
PERSON TO WHOM INFORMATION PERTAINS
Social Security #
Mailing Address (Street & Number)
Telephone #
City, State, Zip Code
(
)
Vehicle License Plate / Identification Number(s) (If Applicable)
Driver License / ID Card Number (If Applicable)
TYPE OF INFORMATION REQUESTED
VEHICLE RELATED
DRIVER RELATED
Printout of Vehicle Registration / Owner Information
Motor Vehicle Record
Copy of Vehicle or Title or MSO
Copies of Citations or Withdrawal Notices
Copy of Bill of Sale
Copy of License / ID Card Application
Other:
____________________________________
Other: ____________________________
__________________________________________
__________________________________
__________________________________________
__________________________________
__________________________________________
__________________________________
Provide additional information to accurately and specifically identify the information requested above:________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Pursuant to the National Driver's Privacy Act, Public Law 103-322, I hereby swear and affirm that this requested release
of information is permissible and will be used according to law.
The undersigned takes full responsibility for any violations of this Act.
I authorize the release of my personal information to:
Me
Authorized Representative
Requestor
Signature of Person
to Whom Information Pertains ___________________________________________________________ Date ________________
If personal information is to be released to anyone other
than the individual, this Release must be notarized.
NOTARY: Subscribed and sworn to before me at _______________________,
this________ day of _________________, 19 ____.
THIS RELEASE IS
Signed______________________________________________________
VALID FOR 30 DAYS
My commission expires: _____________________________
FROM DATE OF AUTHORIZATION
SEAL
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