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New York State Department of Motor Vehicles

GENERAL CONSENT FOR RELEASE OF PERSONAL INFORMATION

(See the other side for instructions.)

I ________________________________________, authorize the New York State Department of Motor Vehicles to disclose

(Motorist)

or otherwise make available to___________________________________ personal information about me obtained by the

(Record requester)

Department in connection with a motor vehicle record.

Motorist’s Signature

STATE OF ___________________________________________

ss:

COUNTY OF _________________________________________

On this ______ day of ________________, ______ before me personally appeared_________________________________,

(1st, 2nd, . . .)

(month)

(year)

(Motorist)

to me known and who by me being duly sworn, acknowledged to be the person described in and who executed the foregoing

consent and he/she duly acknowledged to me that he/she executed the same.

Notary Public

MV-15GC (4/98)

Background

The federal Driver's Privacy Protection Act (DPPA) designates certain information in motor vehicle records as Personal Information.

Personal information includes a motorist's photograph, social security number, driver license number, non-driver ID number, name,

address (except for 5-digit zip code), telephone number, and medical or disability information. It does not include information on vehicle

accidents, driving convictions and driver status. Most motor vehicle records contain personal and non-personal information.

The DPPA also limits the purposes or permissible uses for which the Department of Motor Vehicles may release records containing

personal information. Copies of the DPPA and the permissible uses available in NYS are printed on forms MV-15DPPA and MV-15PU.

Some requesters may request a copy of a record only if they have permission from the person named on the record. This form provides

evidence of that permission.

Instructions for Motorists

The motorist is the person named in a motor vehicle record. You, the motorist, complete the top half of this form. Print your name in the

blank marked Motorist. Print the record requester's name in the blank marked Record requester. Then visit a notary public. In the presence

of the notary, sign on the line marked Motorist's signature and give this form to the notary.

After it is notarized, you may give this form to the record requester.

Instructions for Record Requesters

You may request a motor vehicle record containing personal information only if you have a permissible use as defined in the DPPA. You

may face criminal penalties and civil liabilities if you request a record for which you do not have a permissible use. The motorist's

permission is a permissible use. This form, properly completed and notarized, is evidence of the motorist's permission.

Keep this form for five years after you receive the record you requested.

MV-15GC (4/98)

Form Mv-15gc - General Consent For Release Of Personal Information - New York State Department Of Motor Vehicles