Form Mv-15gc - General Consent For Release Of Personal Information printable pdf download

GENERAL CONSENT FOR RELEASE OF PERSONAL INFORMATION

Background

The federal Driver's Privacy Protection Act (DPPA) designates certain information in motor vehicle records as Personal

Information. Personal information includes a motorist's photograph, social security number, date of birth, driver license

number, non-driver ID number, name, address (except for 5-digit zip code), telephone number, and medical or disability

information. Public information includes reportable accidents, driving convictions, driver status and vehicle information.

Most motor vehicle records contain personal and public information. Please note, if we are authorized to release personal

information, we will not release social security number, phone number, photograph, medical or disability information.

The DPPA also limits the reasons (permissible uses) for which the Department of Motor Vehicles may release records

containing personal information. A copy of the DPPA, and the permissible uses in New York State, are printed on form

MV-15DPPA .

Some requesters may request a copy of a record only if they have permission from the person named in the record. This

form provides evidence (signed authorization) of that permission.

Instructions for Motorists

The motorist is the person named in a motor vehicle record. The record requester is the person requesting information

about the motorist. To complete this form, print your name in the blank marked Motorist. Print the record requester's

name in the blank marked Record Requester. Then visit a notary public. In the presence of the notary, sign on the line

marked Motorist's Signature, then give this form to the notary to notarize.

After it is notarized, give this form to the record requester.

Instructions for Record Requesters

You may request someone else’s motor vehicle record containing personal information only if you have a permissible use as

defined in the DPPA. You may face criminal penalties and civil liabilities if you request a record for which you do not have a

permissible use. Having the motorist's permission is a permissible use. This form, properly completed and notarized, is

evidence of the motorist's permission.

Keep a copy of this form for five years after you receive the record you requested.

I, ______________________________________________, authorize the New York State Department of Motor Vehicles

(Motorist)

to disclose or otherwise make available to__________________________________________ personal information about

(Record Requester)

me obtained by the Department in connection with a motor vehicle record.

Motorist’s Signature

STATE OF ___________________________________________

ss:

COUNTY OF _________________________________________

On this _______________ day of ____________________________ , ____________ before me personally appeared

(month)

(year)

___________________________________________ , to me known and who by me being duly sworn, acknowledged

(Motorist)

to be the person described in and who executed the foregoing consent and who acknowledged to me that he/she executed

the same for the purpose therein stated.

Notary Public

dmv.ny.gov

MV-15GC (10/16)

Form Mv-15gc - General Consent For Release Of Personal Information