Fillable Form 5153 - Bulk/customized Record Request Form printable pdf download

MISSOURI DEPARTMENT OF REVENUE

MOTOR VEHICLE BUREAU — RECORDS

Reset Form

Print Form

FORM

PO BOX 2167, JEFFERSON CITY MO 65105-2167

5153

(573) 526-3669

FAX: (573) 526-7367

BULK/CUSTOMIZED RECORD REQUEST FORM

(REV. 7-2012)

THIS FORM MUST BE COMPLETED AND ACCOMPANY ALL WRITTEN REQUESTS FOR DEPARTMENT OF REVENUE BULK OR

CUSTOMIZED INFORMATION. VERBAL REQUESTS WILL NOT BE PROCESSED. YOU MUST COMPLETE AND SUBMIT THIS FORM

EVERY 12 MONTHS TO CONTINUE TO RECEIVE ON-GOING REPORTS/INFORMATION.

MAIL TO:

MISSOURI DEPARTMENT OF REVENUE

RECORD SALES

P.O. BOX 2167

JEFFERSON CITY, MO 65105-2167

REQUESTOR’S NAME (PLEASE TYPE OR PRINT)

NAME OF AUTHORIZED PERSON

TITLE

COMPANY

SDC ACCOUNT CODE

DPPA SECURITY ACCESS CODE

(REQUIRED TO RECEIVE RESTRICTED DATA FROM OUR

N/A

FILES) ___________________________ (NOT APPLICABLE FOR TAXATION RECORD REQUESTS.)

ADDRESS (

MUST BE THE SAME AS ON FILE WITH DPPA SECURITY ACCESS CODE, IF APPLICABLE). IF DIFFERENT, A NEW DPPA CODE MUST BE REQUESTED FOR EACH SEPARATE ADDRESS. DATA WILL BE SENT TO THIS ADDRESS.

CITY, STATE, ZIP CODE

PHONE NUMBER

E-MAIL ADDRESS

(__ __ __) __ __ __ - __ __ __ __

STANDARD BULK REPORT

(INCLUDE QUANTITY AND FREQUENCY)

LIST PROGRAM # __________________

CUSTOMIZED REPORT

DRIVER LICENSE SYSTEM

DEALER REGISTRATION

TITLES/LIENS

MARINE REGISTRATION

GENERAL MOTOR VEHICLE REGISTRATION

TAXATION INFORMATION

(MAY REQUIRE POWER OF ATTORNEY OR OTHER LEGAL REVIEW PRIOR TO RELEASING)

SELECT RECORDS BY THE FOLLOWING CRITERIA

(BE SPECIFIC)

PURPOSE OF REQUEST

(BE SPECIFIC. IF NOT PROVIDED REQUEST WILL BE DENIED.)

DESCRIBE HOW THE INFORMATION WILL BE USED:

DO YOU PLAN ON RESELLING THE INFORMATION?

Yes

IF SO, PLEASE PROVIDE THE METHOD USED TO

SELL THE INFORMATION AND ANY ASSOCIATED WEB SITES.

SORT DATA OPTIONS - SPECIFY (A) FOR ASCENDING OR (D) FOR DESCENDING

FIRST SORT: DATA FIELD _________________

A OR

SECOND SORT: DATA FIELD _________________

A OR

OTHER

_________________________________________________________________________________________________

(PLEASE SPECIFY)

OUTPUT MEDIA:

COMMA DELIMITED

YES

SECURED FTP SITE

ENCRYPTED COMPACT DISC (CD)

SIGNATURE OF AUTHORIZED REQUESTOR/SECURITY ACCESS CODE NUMBER HOLDER

SIGNATURE

DATE

_ _ / _ _ /_ _ _ _

TO BE COMPLETED BY DEPARTMENT OF REVENUE REPRESENTATIVES

THE ABOVE CUSTOMER IS AUTHORIZED TO RECEIVE THE INFORMATION IN ACCORDANCE WITH THE DRIVER’S PRIVACY PROTECTION ACT (DPPA) OR

SECTION 32.057, RSMo, AND I AUTHORIZE OUR INFORMATION TECHNOLOGY STAFF TO EXTRACT THE INFORMATION ABOVE.

ADMINISTRATOR’S SIGNATURE (OR DESIGNEE):____________________________________________________ SECURITY ACCESS VERIFIED

YES

N/A

REPORT IS ROUTINE/REOCCURING:

YES

IF YES, DISCONTINUE REPORT ON DATE: ___________________ (NOT AUTHORIZED TO PRODUCE REPORT/INFORMATION BEYOND 12 MONTHS.)

BUREAU NAME: ___________________________________________________ DATE: ___________________ DATE SUBMITTED TO ITSD: ___________________

OHD TICKET NUMBER: _______________________

TO BE COMPLETED BY ITSD REPRESENTATIVES

THE DATA ABOVE HAS BEEN EXTRACTED AND FTP’D AND/OR SENT TO THE ADDRESS ON FILE WITH THE DPPA SECURITY ACCESS INFORMATION.

ITSD REPRESENTATIVE SIGNATURE: _______________________________________________________ DATE REQUEST COMPLETED: ___________________

DOR-5153 (7-2012)

Form 5153 - Bulk/customized Record Request Form

Related Articles

Related forms

Related Categories