Form Tc-895 - Application To Request A Motor Vehicle Account Page 2
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2The Utah State Tax Commission reserves the right to notify the individual about whom protected information is
requested.
As the condition of the disclosure of protected records, the applicant expressly agrees to the following terms:
1.
Responsibility
. The Applicant assumes all responsibility for the protected records of the Division that may be disclosed
pursuant to this application in accordance with Utah Code Ann. Section 41-1a-116, 63G-2-202 and the Federal Driver's
Privacy Protection Act, Title 18 Section 2721.
2.
Training.
The Applicant agrees to designate a representative to perform all training required by the Division and to ensure
that the Applicant accesses all protected records in accordance with this application.
The Applicant agrees to notify the Division of any change in the designated representative and/or authorized
individuals that will utilize this access within 10 days from such change
. Changes must be on agency letterhead and
signed by the Applicant. You may fax these changes to (801) 297-7697, Attn: Third Party Representative.
The Applicant agrees to submit the names of all employees that will be utilizing the DMV Information Telephone Account
with this application.
The applicant agrees to notify the Division in writing of any changes to the list of employees
within 10 days of such change.
Changes must be on business letterhead and signed by the Applicant. You may fax these
changes to (801) 297-7697, Attn: Third Party Representative.
The Applicant will conduct any and all training of its employees and agents as directed by the Division. It is anticipated that
training will be required on an annual basis or more frequently depending upon the needs of the Division.
The Applicant shall require all employees, prior to access to the protected records, to execute an acknowledgment that
states substantially as follows:
“The employee understands that access to the Division's records may only be made in connection with the
legitimate business need of the business as permitted by law. Access of the records for an improper purpose,
including personal reasons, is prohibited and subject to penalties imposed by law. If the employee learns of
any improper use or disclosure of the records, he or she shall report such use or disclosure immediately to his
or her supervisor and the Division.”
2.
Maintenance of Records and Audit.
The Applicant agrees to take such steps necessary to ensure the privacy of the records
disclosed under this application. Such steps include instructions and directions that may be provided by the Division, the
marking of all records as “confidential not to be copied” and the maintenance of written documentation substantiating the
basis for the access of each record. For example, if access is made to verify the ownership of a vehicle based upon
information supplied by the owner, the Applicant should have in it's records an application, statement or consent signed by
the owner representing his or her interest in the subject vehicle.
The Applicant agrees to permit the Division reasonable access to all files or documentation pertaining to a disclosed record.
Such access may be on an individual basis, such as an investigation of a complaint, or an audit to determine the
Applicant's compliance with the applicable laws and procedures of the Division.
3.
Limited Use of Records.
The Applicant warrants and represents that the protected records of the Division will only be
accessed for the purpose marked on this application and that such records will not be used, disclosed or disseminated for
any other purpose, including advertising or solicitation purposes in any form. The Applicant understands that the improper
use, disclosure, or dissemination of records accessed under this application may violate applicable law and result in
criminal sanctions and civil liability.
4.
Indemnification.
The Applicant assumes responsibility for the records disclosed and agrees to indemnify and hold harmless
the Division from any and all claims, demands, actions or liabilities that may arise against the Division by reason of the
violation of the aforementioned statutes.
5.
Termination.
This application and the Applicant's access to records of the Division may be terminated and denied for any
reason and at the sole discretion of the Division.
Print applicant's name
Applicant's title
Applicant's signature
Date
X
Print designated representative's name
Designated representative's signature
Date
X
Please allow seven working days for review and processing of application. You will be notified by mail that your application has
been approved, denied or if more information is needed.
Provide names of those individuals that will be utilizing your motor vehicle telephone account below:
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Parent category: Financial