Form Dl-Dppa-1 - Driver Privacy Protection Act Request Form (Page 2 of 2) in pdf

Part I - Request for Driving Records (DR) / Address History

I am requesting a driver license record (DR) for the following person(s), enter name as it appears on the NC driver license:

NCDL/ID # _______________________ Name _________________________________ DOB ____________ SSN ____________

(If more than 10 DRs are needed , a separate sheet may be attached with all the above information for the additional DRs)

Please indicate the type DR you are requesting, fees are set by NCGS 20-26(c) and are as follows:

____ Certified Complete History - $14.00

____ Uncertified Complete - $10.00

____ Uncertified Limited - $10.00

(meets Court requirements)

History

History (3 years)

____ Address History - $13.00

____ Uncertified Limited - $10.00

History (7 years)

I am qualified to receive this information under the category circled on Side 1 (see items 1-12). I understand

that I may not re-disclose this information except for the reasons listed on side 1.

Requested by: Full name (print) ____________________________________________________ Date ___________________________

NCDL/ID # _____________________________ DOB ____________________ SSN or ITIN ___________________________________

Signature (Required) _____________________________________________________

___________________________

(Date)

Mailing Address_____________________________________________________

City _________________ __________________

State ____________________

Zip Code ____________________

Telephone # ____________________

If ordered by mail, please allow 10 business days processing time, this DOES NOT include US Postal Service delivery to or from the DMV. Make checks

payable to NCDMV (ensure that your driver license number is printed or written on your check or money order). M ail requests to NCDMV, Driver

License Records Unit,3113 M ail Service Center, Raleigh NC 27699-3113

NO TICE: It is unlawful for any person to make false representation to obtain any personal information from an individual

motor vehicle record.

DL-DPPA-1

Revised January 2016, previous editions are obsolete DO NOT USE

Form Dl-Dppa-1 - Driver Privacy Protection Act Request Form Page 2