Sd Eform 0821 V5 - Driver'S Privacy And Protection Act Page 2
Download a blank fillable Sd Eform 0821 V5 - Driver'S Privacy And Protection Act in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Sd Eform 0821 V5 - Driver'S Privacy And Protection Act with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3MV/DPPA -11/08
SECTION C - Authorization for Release of Information
I/we hereby certify that I/we are requesting South Dakota motor vehicle records under the provisions of the Federal Driver’s
Privacy and Protection Act. I/we are authorized to obtain these records and personal information based on the following
(please review carefully and check the appropriate entry that allows you authorization to obtain motor vehicle record
information). Please be sure to review all of the choices on this page when checking appropriate authorizations.
As authorized by the record owner (include completed Record Holder Release of Information Authorization Form found in Section D on
back page of this booklet).
For use by any government agency, including any court or law enforcement agency, in carrying out its functions, or any private person
or entity acting on behalf of a government agency in carrying out its functions. (No fee)
For use in the normal course of business by a legitimate business or its agents, employees, or contractors, but only:
1.
To verify the accuracy of personal information submitted by the individual to the business or its agents, employees or contractors,
and
2.
If such information as so submitted is not correct or is no longer correct, to obtain the correct information, but only for the pur
poses of preventing fraud by, pursuing legal remedies against, or recovering on a debt or security interest against, the individual
(Include Sales Tax or Dealer #:
)
For use in connection with any civil, criminal, administrative or arbitral proceeding in any court or government agency or before any
self-regulatory body, including the service of process, investigation in anticipation of litigation, and the execution or enforcement of
judgments and orders, or pursuant to any order of any court.
For use by an insurer or insurance support organization, or by a self-insured entity, or its agents, employees, or contractors, in
connection with claims investigation activities, anti-fraud activities, rating or underwriting.
For use in providing notice to the owners of towed, impounded, or abandoned (any motor vehicle left on a public street or high-
way or left on private property without the permission of the landowner or tenant) vehicles. (No fee)
For use by any licensed private investigative agency or licensed security service for any purpose permitted under the Federal Driver’s
Privacy and Protection Act.
(Private Investigators must complete the following:)
(SD Sales Tax #)
(State Licensed In)
(License #)
For use by an employer or its agent or insurer to obtain or verify information relating to a holder of a commercial driver’s license that is
required under the Commercial Motor Vehicle Safety Act of 1986 (49 U.S.C. App. 2710 et seq.).
You must check the box(es) that apply to you, sign and date the form, and have your signature notarized before your
request will be processed.
I certify under penalty of perjury that all information completed is true and correct, and the willful, unauthorized disclosure of
information from any department record for a purpose other than that stated in the request, or the sale or other distribution of
the information to a person or organization not disclosed in the request may be subject to liability in a civil action brought by
the driver to whom the information pertains and may result in penalties imposed under Title 18 U.S.C. Section 2724.
(Signature of Requestor)
(Date)
Subscribed and sworn before me this
day of
, 20
.
(Seal)
My commission expires on:
(Notary Public Signature)
If your request for information has been authorized by the record owner, you must include a notarized affidavit from the record holder
that gives a complete description of the vehicle and that authorizes the release of the information.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Sd Eform 0862 V5 - South Dakota Salvage, Recovered Theft, And Uniform Damage Disclosure Statement
Financial
Sd Eform 1932 V5 - South Dakota Streamlined Sales Tax Agreement - Certificate Of Exemption
Financial
Sd Eform 0262 - 2007 Employer's Report To Determine Liability Form - South Dakota Department Of Labor
Legal
Related Categories
Parent category: Financial