Fillable Form 4678 - Request For Security Access Code printable pdf download

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MISSOURI DEPARTMENT OF REVENUE

FORM

MOTOR VEHICLE BUREAU — RECORDS

PO BOX 2167, JEFFERSON CITY MO 65105-2167

4678

(573) 526-3669 FAX: (573) 526-7367 E-mail: mvrecords@dor.mo.gov

OFFICE USE ONLY

REQUEST FOR SECURITY ACCESS CODE

(REV. 07-2013)

SECURITY CODE ASSIGNED __________________

INSTRUCTIONS: This form must be fully completed and approved before a Requester can obtain access to restricted information.

Only Requesters who meet the criteria outlined in Section B are eligible to obtain restricted information and a security access code.

REQUESTING:

New Security Access Code (first time)

Modify Information

Recertification

SECTION A. REQUESTER INFORMATION

NAME OF INDIVIDUAL OR ORGANIZATION

Check one:

Individual

Partnership

Corporation

LLC

News Media

Government Agency

ALL PERSONNEL AUTHORIZED TO REQUEST INFORMATION:

CHECK AND ATTACH LIST IF NECESSARY

E-MAIL ADDRESS (REQUIRED FOR FUTURE NOTIFICATIONS)

TELEPHONE NUMBER

FAX NUMBER

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

STREET ADDRESS (PHYSICAL LOCATION)

CITY

STATE

ZIP CODE

__ __ __ __ __

MAILING ADDRESS (IF DIFFERENT)

CITY

STATE

ZIP CODE

__ __ __ __ __

SECTION B. PURPOSE OF REQUEST

Requester hereby certifies to the Missouri Department of Revenue (Department) that this request for Missouri motor vehicle or driver license

records or information is made under the provisions of the federal Driver’s Privacy Protection Act (DPPA) and Missouri law.

TYPE OF INFORMATION REQUESTED:

DESCRIBE HOW INFORMATION WILL BE USED:

Yes

DO YOU PLAN ON RESELLING THE INFORMATION?

IF SO, PLEASE PROVIDE THE METHOD USED TO SELL THE INFORMATION AND ANY ASSOCIATED WEB SITES.

Please carefully review and check all boxes that apply to Requester’s request for access to personal information on a restricted

record. Requester is seeking information:

(01) As a government agency (federal, state, or local) or on behalf of a government agency, in carrying out its government functions.

(02) As a court (federal, state, or local) or on behalf of a court, in carrying out its court functions.

(03) As a law enforcement agency (federal, state, or local) or on behalf of a law enforcement agency, in carrying out its law enforcement

functions.

(04) For use in connection with matters of motor vehicle or driver safety and theft; motor vehicle emissions, motor vehicle product

alterations, recalls, or advisories; performance monitoring of motor vehicles, motor vehicle parts and dealers; motor vehicle market research

activities, including survey research; and removal of non-owner records from the original owner records of motor vehicle manufacturers.

(05) For use as a legitimate business only (a) to verify the accuracy of personal information submitted by an individual to the business

or its agents, employees, or contractors and (b) if such information is not correct, to obtain the correct information, but only for the purposes

of preventing fraud by pursuing legal remedies, or recovering on a debt or security interest, against the individual. (For individual

requests only.)

(06) For use in connection with any civil, criminal, administrative, or arbitral proceeding in any federal, state, or local court or 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 an order of a federal, state, or local court.

(07) For use in research activities, and producing statistical reports, so long as the personal information is not published, redisclosed,

or used to contact individuals.

(08) As an insurer, insurance support organization, or self-insured entity for use in connection with claims investigation activities, anti-fraud

activities, rating or underwriting.

(09) For use in providing notice to the owners of towed or impounded vehicles.

(10) For use by a licensed private investigative agency or licensed security service for a purpose permitted herein.

(11) For use as an employer, its agent or insurer in obtaining or verifying motor vehicle or driver record information relating to a holder

of a commercial driver’s license (CDL).

(12) For use in the operation of a private toll transportation facility.

(13) To disseminate to the public in a newspaper, book, magazine, broadcast, or similar form of public communication, when such

dissemination is related to the operation of a motor vehicle or to public safety.

For more information, visit

DOR-4678 (07-2013)

Form 4678 - Request For Security Access Code

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