Dvs Records Request - Dl Record - Minnesota Department Of Public Safety Page 2
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4DVS Records Request
C. Requester's Information - Please select one:
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 and complete the additional required
information.
Authorization:
PERMISSIBLE USES OF MOTOR VEHICLE DATA AS PROVIDED IN UNITED STATES CODE, TITLE 18, SECTION 2721
You must tell us why you want the records you are requesting. Sign your initials next to each use under which you claim access.
Driver and Vehicle Services reserves the right to request such additional information as may be necessary to determine whether
you qualify for access.
The requestor is an employee of a federal, state, or local government agency, or a private person acting on behalf of a federal,
state, or local government agency, and the records will be used to carry out the official functions of such federal, state, or local
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government agency. (Please attach proof of Requestor's authority to act on behalf of a government agency.)
Name of agency:
Name of agency's contact:
Telephone number of contact:
Email address of contact:
The records will be used 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
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vehicle market research activities, including survey research, and removal of non-owner records from the original owner records of
motor vehicle manufacturers. (A written explanation detailing the reasons you contend that you qualify for access under this category
must be attached to this Agreement.)
The records will be used in the normal course of business by a legitimate business or its agents, employees, or contractors but only
(i) to verify the accuracy of personal information submitted by the individual to the business or its agents, employees, or contractors,
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and (ii) if such information as so submitted is not correct or is no longer correct, to obtain the correct information, but only for the
purpose of preventing fraud by, pursuing legal remedies against, or recovering on a debt or security interest against, the individual.
Name of business:
Name of business's contact:
Business tax ID number:
Telephone number of contact:
Email address of contact:
The records will be used in connection with a civil, criminal, administrative, or arbitral proceeding in federal, state, or local court or
4.
agency or before a self-regulatory body, including the 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.
Requestor is (check one):
attorney
represented litigant
pro se litigant
other (attach explanation)
Name of court, agency, or self-regulatory body:
Name of involved parties:
Name of court:
Name of case or matter:
Expected forum:
Name of case or matter:
Case/matter number:
Date of occurrence:
Case number:
The records will be used in research activities and for use in producing statistical reports, but the personal information in the records
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will not be published, re-disclosed, or used to contact the individual. (A written explanation detailing the reasons you contend that
you qualify for access under this category must be attached to this Agreement.)
The requestor is an agent, employee, or contractor of an insurer or insurance support organization, and the record will be used in
connection with claims investigation activities, anti-fraud activities, rating, or underwriting. (Please attach proof of the Requestor's
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status.)
Name of insurer or insurance support organization:
Name of insurer or support organization's contact:
Telephone number of contact:
Email address of contact:
PS2502A-20 (04/16)
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