Form Ds-19 - Article 19-A Motor Carrier Accident And Conviction Notification Program Application
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1
2ARTICLE 19-A MOTOR CARRIER ACCIDENT AND
CONVICTION NOTIFICATION PROGRAM APPLICATION
(Escrow Account & Driver’s Privacy Protection Act Compliance)
Article 19-A of the New York State Vehicle and Traffic Law (VTL), Section 509-i(4) requires all motor carriers to establish an escrow
account which shall be used to pay for the costs incurred by DMV when it informs the motor carrier of a driver’s conviction or accident.
INSTRUCTIONS:
Please print clearly.
1. The Carrier must complete all sections on page 1 and page 2 of this form.
2. Review the opening deposit table below to determine the required opening escrow deposit amount.
Number of drivers to enroll in the 19-A program
Opening Deposit to send to DMV
0 to 25
$10.00
26 to 65
25.00
66 to 115
40.00
116 to 225
50.00
More than 225
70.00
3. Make your check or money order payable to “
Commissioner of Motor Vehicles
”
(
never send cash) and mail it with this
completed form to:
NYS Department of Motor Vehicles, Bus Driver Unit, 6 Empire State Plaza, Room 136B, Albany, NY 12228.
Motor Carrier Information:
Motor Carrier’s Name: ________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
City: ____________________________________________________ State ___________
Zip Code: ______________________
-
Federal Employer ID Number (FEIN):
Location where the Motor Carrier maintains drivers’ records for audit:
Address: ____________________________________________________________________________________________________
City: _______________________________________________________ State: _________ Zip Code: ________________________
(
)
(
)
Telephone: _____________________________ ext. ________
Fax: (optional) ______________________________ ext. ________
E-Mail: ___________________________________________________________________ (optional)
Person responsible for maintaining the 19-A records of the Motor Carrier’s drivers:
Name:____________________________________________________________________________________________________
(
)
Telephone: ___________________________ ext. ________
Person responsible for billing:
Name: __________________________________________________________________________________________________
Address: ________________________________________________________________________________________________
City: _______________________________________________________ State: _________ Zip Code: ____________________
(
)
(
)
Telephone: ___________________________ ext. ________
Fax: (optional) _____________________________ ext. ________
E-Mail: _________________________________________________________________ (optional)
ç
FOR
DMV approval by: (Sign
)
DMV OFFICE
Print Name:
USE
Date (mm/dd/yyyy):
Title:
PAGE 1 OF 2
DS-19 (3/15)
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