Fillable Form Tc-890 - Release Of Protected Motor Vehicle Information printable pdf download

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Utah State Tax Commission, Division of Motor Vehicles

Release of Protected Motor Vehicle Information

210 N 1950 W, Salt Lake City, UT 84134

Requester's name

Telephone:

Requested vehicle record

See Attached List.

plate number, VIN ,or

Fax:

owner's name

Company

DMV phone account number

(Office Use Only)

Requester's address (

this release is

NOT COMPLETE

without street, city, and ZIP

)

Current plate

Certificate of Inspection (TC-661) is required

Justification Statement (this document must be signed below)

for each vehicle

Mail Microfilm

Out of state search

Fax ($4 each record)

Mail ($3 each record)

($6.50 each record)

($2 each record)

Check one of the following boxes that describes why you are entitled to protected motor vehicle information as permitted by Utah Code

Section 41-1a-116, 63 -2-201 and the Federal Driver’s Privacy Protection Act,

U. S. C.

Title 18

Chapter 123

Section 2721. This information

may only be used in one of the ways listed. If this protected information is disclosed federal and state penalties will apply.

If you are faxing or mailing your request, and do not have a

"DMV phone account," you must include a copy of your license and/or identification.

For use by any licensed private investigative agency, licensed security service or attorney for purposes provided by law.

License number: ____________________

Expiration date: ____________________

Case file name or file number _____________________.

If you checked this box, you must also check one additional box below or submit documentation explaining how request

is supported by Federal Drivers Privacy Protection Act, i.e. court order, subpoena, summons or complaints, etc.

The person making the request is the owner, or in the case of an incorporated business, an officer of the corporation.

Identifying number from picture I.D.: _____________________. I.D. issued by ___________________________.

For use by a government agency, including any court or law enforcement agency, in carrying out their functions.

Identifying number from government picture I.D. _____________________. I.D. issued by ___________________________.

For use by a legitimate business, in the normal course of business, to verify the accuracy of personal information submitted by the individual.

Check

I am a dealer (Dealer no. or FEIN: _________________)

I am a financial institution (FEIN: __________________)

one:

I am a motor carrier and am listed on the motor vehicle record (DOT no. or FEIN: __________________)

For use by any insurer or insurance support organization, or by a self-insured for entity claims investigation activities.

Case file name or file number _____________________.

Insurance organization name _______________________________.

For use to provide notice for one of the following (can not be for debt collection, asset recovery, or skip tracing purposes):

Owner of towed or impound vehicles - must provide copy of tow bill.

Tower business license number: __________________.

State: ____________.

Mechanics lien to vehicle owners - must provide copy of signed repair bill.

Mechanics business license number: __________________.

State: ____________.

Storage lien to vehicle owners - must provide copy of signed storage agreement.

Mobile home park residency - must provide copy of signed rental/lease agreement.

For use by any requester with a NOTARIZED, written consent from the individual who is the name on record.

Must submit an original or certified copy of notarized consent.

For use by any person or entity for service of process or in connection with an order of a court.

Must submit a copy of the summons or order with this application.

Other (please explain)

Requester's Signature and Employees Authorized to Receive Protected Records

* The Tax Commission reserves the right to notify the individual about whom protected information is requested.

As the requester of this information and the signer of this form, I assume all responsibility for the protected motor vehicle record(s) I am

requesting as outlined in Utah Code Sections 41-1a 116 and 63 -2-202, and the Federal Driver's Privacy Protection Act, U. S. C. Title 18

Chapter 123

Section 2721. I affirm that I am entitled to this information pursuant to the reason(s) marked above; and acknowledge that the

information requested can only be used for the purpose stated on this application; and this information may not be disseminated or disclosed

for any other purpose, including advertising or solicitation purposes. Dissemination or disclosure may violate Utah Code 6

-2,

53-9-116

and

U. S. C. Title 18 Chapter 123. As a condition of the disclosure of the records requested in this application, I assume responsibility for the

records disclosed and agree to indemnify and hold harmless the Division of Motor Vehicles from any and all claims, demands, actions or

liabilities that may accrue against the Division by reason of the violation of the aforementioned statutes.

Requester's signature

Date signed

TC-890 Rev. 6/10

Form Tc-890 - Release Of Protected Motor Vehicle Information

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