Request Form For Vehicle Information Page 2
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2C.) Vehicle Information Requested •
Please check type of information needed.
record holder will be withheld on individual requests that do not comply with the Uniform Motor Vehicle Records Disclosure Act.
You may not obtain information about others without their signed written consent unless the request is made by a company/business
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sure Act (17A-2A-1 et seq.).
Basic Vehicle Registration Information - $1.00
Form 62 - Fees and Privilege Tax Paid At Titling - $5.00
Lien Perfection Information (Must include Dealer’s fax date) - $20.00
Lien/Basic Vehicle Registration Information - $5.00
$10.00
Title Copy - $5.00
Title History - $25.00
FEES COVER THE COST OF RESEARCH AND ARE NON-REFUNDABLE.
D.) Request Details
Year ______ Make ____________ Plate _______________ VIN ________________________________________________________
Name _________________________________ Address _______________________________________________________________
Year ______ Make ____________ Plate _______________ VIN ________________________________________________________
Name _________________________________ Address _______________________________________________________________
Year ______ Make ____________ Plate _______________ VIN ________________________________________________________
Name _________________________________ Address _______________________________________________________________
Year ______ Make ____________ Plate _______________ VIN ________________________________________________________
Name _________________________________ Address _______________________________________________________________
** For Additional Requests, attach addendum.**
E.) Requester Signature
I hereby certify that _________________________________________ will use the vehicle information requested pursuant to Section §17A-2A-1 et seq.
of the West Virginia Code, for the purpose checked on side one, section C only and for no other reason. I/we state that I/we have read and signed
this form after its completion, and I/we swear or a rm that the statements made herein are true and correct, and that any statement made on or
pursuant to this form is subject to penalties which shall include punishment or a ne not exceeding $500 or a term of imprisonment not more
than six months, or both.
A copy of a driver’s license or state issued photo ID MUST be attached. No information will
be given without a state issued photo ID. A copy of your request may be forwarded
to the record holder.
(X)
/
/
SIGNATURE OF REQUESTER
DATE
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