Sd Eform 0821 V5 - Driver'S Privacy And Protection Act Page 3
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3SECTION D – RECORD HOLDER RELEASE OF INFORMATION AUTHORIZATION
RECORD HOLDER PERSONAL INFORMATION (ONLY COMPLETE IF RECORD HOLDER IS GIVING
EXPRESSED AUTHORIZATION)
Name: ________________________________________________________________________________________
Address: ______________________________________________________________________________________
Street/PO Box
City
State
Zip Code
SD Driver’s License # or Social Security #: _____________________________________________________
Telephone #: _______________________________
MOTOR VEHICLE RECORD INFORMATION
Year:______________________ Make:______________________________________________________________
Model: _______________________________ Title #/VIN#: ___________________________________________
AUTHORIZATION FOR RELEASE
I hereby give my authorization for the release of all information contained in the Division of Motor
Vehicles’ files on the above listed vehicle to the following:
__________________________________________________________________________________________________
First Name
Middle Initial
Last Name
__________________________________________________________________________________________________
Signature of Registered Owner of Record
Subscribed and sworn before me this ______ day of ________________________________________, 20_____
My commission expires on: ________________________________________________________________________
__________________________________________________________________________________________________
Notary Public Signature
ONLY ONE RECORD PER REQUEST. QUESTIONS CAN BE DIRECTED TO: DMV, 445 EAST CAPITOL AVE.,
PIERRE SD 57501; 605/773-3541.
CLEAR FORM
PRINT FOR MAILING
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