Privacy Act Agreement For Request Of Motor Vehicle Records printable pdf download

Form 431069 (02-14)

New

Office of Driver Services and Vehicle Services

Motor Vehicle Division

Renewal

PRIVACY ACT AGREEMENT

FOR REQUEST OF MOTOR VEHICLE RECORDS

INSTRUCTIONS:

OFFICIAL USE ONLY

● This Privacy Act Agreement for Request of Motor Vehicle

Date Received:

Records must be completed and approved before a Requestor

Required:

Allowed:

can obtain personal information or highly restricted personal

Authorized

Personal Information:

information from the Iowa Department of Transportation. Only

Access For:

Highly Restricted Personal Information:

Requestors who meet the criteria outlined in Part C are eligible

to obtain such information from the Iowa Department of

Authorized

DOT employee:

Transportation. This Agreement must be completed with all

By:

User ID given:

required attachments before the Iowa Department of

Password given:

Transportation will consider a request for motor vehicle

records.

VTN record given:

VTNP record given:

Record access given:

●

Requestor must attach a legible photocopy of his or her

Photo File access given:

driver's license or non-driver identification card.

Requested access denied:

●

Requestor must print his or her full name on each page of

this Agreement.

Date access given/denied:

● An Iowa Department of Transportation employee will

Legal Reviewer:

contact Requestor to advise whether the request is approved

Date of review by Legal:

or denied.

PART A. REQUESTOR INFORMATION

(This Section Must Be Completed. Each blank space in this Part must be completed.

If you do not provide information for a space, you must write "N/A" for "not applicable".)

Please Check One Box:

I am requesting a copy of my own record.

I am requesting a copy of the record of another person, and I have attached their written consent.

Other - for all other record requests, you must initial at least one permissible use in Part C of this Agreement, and you

must check at least one of the following boxes:

I am making a one-time request, and I will use the record one time and for one purpose.

I am requesting on-line record access. (Skip Part B of this form if you are requesting record access.)

I am requesting Photo File access. (Skip Part B of this form if you are requesting Photo File access.)

Name of Requestor (Last)

(First)

(Middle Initial)

Address

Driver License or Non-Driver ID Number

City

State

ZIP Code

Email Address

Telephone Number

Fax Number

(

) -

(

) -

Requestor is an Authorized Representative of (List Name of Person or Entity)

D-

List dealer number if dealership

Person/Entity Address

City

State

ZIP Code

PART B. INFORMATION REQUESTED

(Provide As Much Information As Possible If This Is A One-Time Request)

Name (Last)

(First)

(Middle Initial)

Address

City

State

ZIP Code

Driver License or Non-Driver ID Number

Date of Birth

Social Security Number

Sex

Year and Make of Vehicle

Vehicle Title Number

License Plate Number

Vehicle Identification Number (VIN)

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Privacy Act Agreement For Request Of Motor Vehicle Records

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