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


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
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
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 ___________________________________________
COUNTY OF _________________________________________
On this _______________ day of ____________________________ , ____________ before me personally appeared
___________________________________________ , to me known and who by me being duly sworn, acknowledged
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
MV-15GC (10/16)


00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal