Privacy Act Agreement For Request Of Motor Vehicle Records (Page 4 of 4) in pdf

Print Requestor's Full Name

PART D. CERTIFICATION (This Section Must Be Completed)

By signing this Privacy Act Agreement Request for Motor Vehicle Records and initialing each item below, I, the Requestor, certify that:

I am familiar with all provisions of the federal Driver Privacy Protection Act of 1994, 18 U.S.C. §§ 2721-2725, and Iowa

Code section 321.11, which limit access to personal information and highly restricted personal information from the Iowa Department of

Transportation's motor vehicle records.

I understand that "personal information" means information that identifies an individual, including an individual's

photograph, social security number, driver identification number, name, address, telephone number, and medical or disability information. I

further understand that "highly restricted personal information" means an individual's photograph or image, social security number, and

medical or disability information.

I will abide by the terms of federal and state law, including, but not limited to, those laws restricting access to personal

information and highly restricted personal information from the Iowa Department of Transportation's motor vehicle records only to those

persons and for those purposes which are permitted under both laws, and for no other purpose.

I understand that I am prohibited from re-disclosing the information I obtain from the Iowa Department of

Transportation pursuant to this Agreement, except in accordance with applicable law.

I will keep a record for five (5) years of the following: (1) all persons to whom I re-disclose or re-sell information

obtained under this Agreement, and (2) the purpose for which the information is to be used. I agree to make such records

available to the Iowa Department of Transportation upon request.

I shall be liable for, and shall indemnify, defend, and hold harmless the Iowa Department of Transportation, its agents,

officers, and employees for any misuse or misappropriation of any personal information in a record obtained from the Iowa Department of

Transportation in connection with this Agreement, including misuse or misappropriation by any of my employees, servants, agents, or

contractors.

I shall further indemnify, defend, and hold harmless the Iowa Department of Transportation, its agents, officers, and

employees, for and against any and all losses, damages, judgments, liabilities, or similar costs and expenses which arise in whole or in part

out of my acts or omissions with respect to the laws restricting access to and disclosure of motor vehicle records including, without

limitation, reasonable attorneys' fees and all other costs of defending against such action or claim.

I have attached a legible photocopy of my driver's license or non-driver identification card.

9a.

In executing this Agreement, I am acting on my own behalf, and not as an employee, agent, officer, conservator,

attorney-in-fact, or other representative or official capacity for another person or entity. (If you initial this paragraph, skip paragraph 9b. If

you do not initial this paragraph, please continue to paragraph 9b.)

9b.

In executing this Agreement, I am acting as an employee, agent, officer, conservator, attorney-in-fact, or other

representative or official capacity for another person or entity. I have proper authority to execute this Agreement on behalf of such person

or entity, and to bind such person or entity to the requirements of this Agreement, including, but not limited to, the requirements of

paragraphs 3, 4, 5, 6, and 7 of this Part D. My execution of this Agreement is my free and voluntary act and the free and voluntary act of

such person or entity, and so binds such person or entity. (If you do not have proper authority to execute this Agreement on behalf of such

person or entity, do not initial this paragraph and do not execute this Agreement. The Agreement should be executed on behalf of another

person or entity only by a person with the proper authority to do so. If you initialed this paragraph, you must provide your title or

representative/official capacity on the line below.)

Title or representative/official capacity:

10.

I understand that, if the Iowa Department of Transportation grants me access to Motor Vehicle Records by way of this

Agreement, and then, at any time thereafter, finds that I have misused or misappropriated such records, the Iowa Department of

Transportation may, with or without notice to me, terminate my access to such records.

The Iowa Department of Transportation reserves the right to request additional information to determine proper authority to execute and

enter into this Agreement.

I certify under penalty of perjury and pursuant to the laws of the State of Iowa that all information completed and contained in

Parts A, B, C, D, and any attachments hereto, is true and correct.

I so certify this

day of

Requestor's Signature

, 20

Please Print Requestor's Full Name

This Privacy Act Agreement For Request of Motor Vehicle Records replaces all previous Privacy Act Agreements on file with

the Iowa Department of Transportation.

(Page 4 of 4)

Privacy Act Agreement For Request Of Motor Vehicle Records Page 4

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