Fillable Indiana Form 53789 Request For Driver Records printable pdf download

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BUREAU OF MOTOR VEHICLES

REQUEST

FOR DRIVER RECORDS

Attn: Driver Records Requests

State Form 53789 (R11 /

2-15)

100 N. Senate Ave., Rm N412

Approved by State Board of Accounts,

2015

Indianapolis, IN 46204

Bureau of Motor Vehicles

The Indiana Bureau of Motor Vehicles (BMV) driver and vehicle records are open to the public except those protected by law. Recipients of

records must comply with the applicable state and federal privacy laws for usage, distribution, and record keeping.

Information in a record that identifies a person

is statutorily restricted by Ind. Code §§ 9-14-3-5, 9-14-3.5-5, and 9-14-3.5-7and can only be

released in the circumstances outlined

below.

A person’s name, address, or telephone number can only be released if:

(1) you provide written consent of the person to whom the personal information pertains; or

(2) you provide proof of identity and a representation that use of the information will be strictly limited to at least one of the uses outlined in Ind.

Code § 9-14-3.5-10. You must specify which use in Ind. Code § 9-14-3.5-10 applies to you. A person’s image, Social Security number, medical or

disability information, driver’s license number, federal identification number, or a reproduction of his/her signature on his/her application for an

Indiana ID card, learner’s permit, or driver’s license can only be released if:

(1) you provide the express written consent of the person to whom the information pertains; or

(2) you provide proof of identity and a representation that use of the information will be strictly limited to at least one of the uses outlined in Ind.

Code § 9-14-3.5-10(1), Ind. Code § 9-14-3.5-10(4), Ind. Code § 9-14-3.5-10(6) or Ind. Code § 9-14-3.5-10(9). In your request, you must

specify which use in Ind. Code § 9-14-3.5-10 applies to you.

Records will not contain confidential juvenile information, unless you, as the requestor, are the individual to whom the information belongs, or the

parent, legal guardian, or authorized representative of that individual. If you otherwise are entitled to confidential juvenile information, you must

obtain it from the appropriate court.

Many of the BMV public records are immediately available through a subscription to the online service at IN.gov. Your own records are also

immediately available online at . Paper copies may be requested by completing this form.

INSTRUCTIONS:

1. Complete in blue or black ink or type.

2. Complete all five (5) steps when requesting records. If any of the steps are not completed, the request will be returned.

STEP 1 - Complete applicable information.

STEP 2 - Complete as many identifiers as possible.

STEP 3 - Only check one box except if the request is for Confidential Juvenile Information. Additional record requests

must be completed on separate forms.

STEP 4 - Must provide at least one qualification and complete the intended use of the record.

STEP 5 - Indicate the payment amount, sign and date the request form.

3. Include payment with completed form. Acceptable forms of payment are money order, cashier’s check, business check or

personal check (customer must have an INDIANA BMV record to process a personal check ). Make checks payable to the

Bureau of Motor Vehicles.

4. Mail the completed form to the address indicated above.

5. Please allow two (2) to four (4) weeks to process this request.

STEP 1:

The person submitting this form must provide the following information.

Telephone number

E-mail address

(first name, middle name, last name)

Name of person or business

(number and street, city, state and ZIP code)

Mailing address

Last 4 digits of Social Security Number

Last 4 digits of record of admission number

Federal identification number

if requestor is a

(This information is for security purposes only.)

(I-94 ) (if applicable)

business

(This information is for security purposes only.)

XXX-XX-__________

XXXXXXX_________

STEP 2:

Person named in Step 1 is requesting information on the following person. (Please include as many identifiers

as possible, as drivers often have identifiers in common.)

I consent to the release of my restricted information (defined above) to the requestor.

PRINTED NAME: _______________________________ SIGNATURE: _______________________________________

(first name, middle name, last name)

, if known

Name of driver

Driver’s license number

Last 4 digits of driver’s social security number,

Last 4 digits of record of admission number

(mm/dd/yyyy), if known

Driver’s date of birth

if known

(I-94) (if applicable)

XXX-XX-

XXXXXXX_________

(number and street, city, state and ZIP code)

Last known Indiana mailing

address

Indiana Form 53789 Request For Driver Records

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