Form Bdvr-155 - Record Lookup Request For Governmental Agencies - Michigan Department Of State Page 2
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2Section 5. Requestor Certification (This section must be completed or request will not be processed.)
I certify that this requested record information is for use by a federal, state, or local governmental agency, including a court or law
enforcement agency in carrying out the agency’s functions. I also certify that the information and statements on this request are true,
correct, and comply with the provisions of state and federal driver privacy laws. I understand that the willful unauthorized disclosure of
personal information obtained from these record(s) for a purpose not outlined by my government employing agency, or the sale or other
redisclosure of information to a person or organization not identified in this request, may result in penalties imposed under MCL 28.295a,
257.902, 257.903, 324.80130d, 324.80319a, 324.81120, 324.82160 and other provisions of law.
X
___________________________________________
____ / ____ / ____
Signature of Requestor – form must be signed or request will not be processed.
Date
Penalties for Misuse: Under Michigan law, a person who makes a false representation or a false certification to obtain
personal information or who uses personal information for a purpose other than a permissible purpose identified in
law is guilty of a felony, which may be punishable by imprisonment for up to 5 years and/or a fine of up to $5,000.
Subsequent convictions may result in imprisonment for up to 15 years and/or a fine of up to $15,000.
INSTRUCTIONS FOR COMPLETING THIS FORM
Fill out as much information about your request as you can. Accurate and complete information will help us locate the record(s) you
want. Records will only be mailed to the address listed on your Michigan Department of State account. Please include a daytime
telephone number in case we have questions about your request.
Government agencies that do not have a Michigan Department of State account number need to enclose a cover letter on
agency letterhead, along with this request form, requesting that an account number be issued for current and future use. A
cover letter will not be necessary if you already have a Michigan Department of State account number documented in Section
2 of this request form.
For driving records, include as much detail in Section 3 as possible. If you just need the name, address, or driving status, request the
current record only. If you only want a driving record, do not complete Section 4.
Personal identification card information is also available. Complete Section 3, Driver Information, substituting the identification card
number for the driver’s license number.
For vehicle information, include as much detail as possible. The owner’s name should be the owner of record, not a purchaser who
has not yet titled the vehicle. If you just need name, address, or ownership verification, request only a registration record.
Information about proof of insurance at vehicle registration is not retained and is not available.
For watercraft, snowmobile, ORV, or mobile home records, complete Section 4, Registration or Title Information, substituting the
watercraft or snowmobile registration number for the license plate number or substituting the mobile home serial number for the
vehicle identification number. Include as much information as you can about the watercraft, snowmobile, ORV, or mobile home.
* When requesting records for all motor vehicles or all assets registered and/or titled through the Michigan Department of State
for individuals and/or companies, precise information is required. Information retrieved is based upon an exact name and address
match. The individual’s name and address, as provided by the record requestor, must match the name and address on the record(s)
held by the Michigan Department of State.
Mail your completed request to:
Michigan Department of State
Record Lookup Unit
7064 Crowner Drive
Lansing, Michigan 48918-1540
Read the instructions for guidance or call 517.322.1624 for help in completing this form.
Completed requests may be faxed to 517.322.1181.
BDVR-155 (09/10)
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