Criminal Record Release Authorization Form - New Hampshire Department Of Safety, Form Dsmv 505 - Release Of Motor Vehicle Records Page 2
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3RELEASE OF
NH DEPARTMENT OF SAFETY
Division of Motor Vehicles
MOTOR VEHICLE
23 Hazen Drive, Concord, NH 03305
RECORDS
Tele:
Driver Records
(603) 271-2322
Registration
(603) 271-2251
Repro/Accidents
(603) 271-2128
Title
(603) 271-3111
(Pursuant to RSA 260:14)
Fax
(603) 271-1061 (all areas)
Form DSMV 505
(Rev. 03/05)
I. Requested Information:
II. Requestor Information:
Are you requesting:
Name of Requestor
.
Your Motor Vehicle Record?
A
: ____________________________________________________
Another person’s Motor Vehicle
B.
Employer/Company
: _______________________________________________
Record?
(If applicable)
The back of this form must be completed and notarized.
C.
Another person’s Motor Vehicle
Address: ________________________________________Tele.#: ___________________
Record as an authorized agent of
your employer or a company?
City: ___________________________________ State: __________ Zip: ______________
A Certificate of Authority must accompany this request, or one
must be on file with the Division of Motor Vehicles.
III. Requested Records:
IV. Intended Use of Information:
IMPORTANT:
To be completed only if you checked Box C above
Driver Record (Certified copy):
$ 10.00
For use in connection with any civil, criminal, administrative or arbitral proceeding.
Docket # _____________________ Court: ____________________[RSA 260:14 V (a)(2)].
Driver Record (Non-Certified copy):
$ 8.00
By a bank or similar institution to verify the accuracy of personal information submitted by
the individual to the bank [RSA 260:14 V (a)(3)].
Driver Record (Insurance copy):
$ 8.00
For providing notice to the owner(s) of a towed or impounded vehicle [RSA 260:14 V (a)(5)].
Registration Listing (Current Information Only): $ 5.00
For use by any private investigative agency or security service licensed by this state for any
purpose permitted pursuant to RSA 260:14, V (a), other than for bulk distribution for
surveys,
marketing
or
solicitations
pursuant
to
RSA
260:14,
V
(a)(8)
Registration (Certified copy):
$ 10.00
__________________________
[RSA
260:14
V
(a)(6)].
Indicate specific reason here
Title Search:
$ 20.00
By an employer or its agent or insurer to obtain or verify information relating to a holder of a
commercial driver’s license [RSA 260:14 V (a)(7)].
By a public utility to perform its public service obligation provided the individual has given
License Applications and Letters of Verification: $ 10.00
their express consent [RSA 260:14, V (a)(9)].
Insurance Card (Accident use only):
$ 1.00
For an insurance company or by its authorized agent [RSA 260:14 IV (a)(2)].
Vehicle or boat information only.
Accident Report
(Requestor will be notified of cost):
$ 1.00 per page ($5.00 minimum)
For use by a life insurance company authorized to write life insurance policies in New
Hampshire, or its authorized agent. In checking off this box, I represent that the
Other: _______________________________: $______
named person’s written consent to the release of the record has been obtained
and that the record will be used solely in connection with claims investigation,
Make checks payable to “State of NH – DMV”
rating, and underwriting. ________________ [(RSA 260:14, V(a)(10)]
(Initial here)
V. Search For (provide all applicable information):
Last Known Address: ________________________________
Name:____________________________________________
__________________________________________________
Date of Birth: ______________________________________
Date of Accident: ____________________________________
Registration/Plate #: _________________________________
Location of Accident: _________________________________
Driver License/I.D. #: ________________________________
Route/Street
City/Town
________________________________
Vehicle Identification #:
Other Identification Information:
____________________________________
***Reverse Side Must Be Completed Before Processing***
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