Criminal Record Release Authorization Form - New Hampshire Department Of Safety, Form Dsmv 505 - Release Of Motor Vehicle Records Page 3
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3VI. Signed Authorization:
If you are requesting your record be released to another person, the authorization of the person listed in
Section V “Search For” must be acknowledged by a Notary Public or a Justice of the Peace on the back of
this form.
Notary Public / Justice of the Peace Acknowledgement:
Certification:
I authorize my record to be released to a third person:
I have read RSA 260:14 and I understand the
limitations placed on the use of information
____________________________________________________ Date:_____________
received by the Department of Safety. This form
(Signature)
is signed under penalty of unsworn falsification
State of _______________, County of: ___________________ss Date: _____________
pursuant to RSA 641:3 and subject to the
penalties specified in RSA 260:14, IX.
The above named ______________________________ personally appeared and made oath
that the above declaration by him is true.
____________________________________
In witness whereof I hereunto set my hand and official seal:
Signature of Requestor
_____________________________________
_______________________
Date: _____________
Notary Public/Justice of the Peace
Commission Expiration
VIII. PENALTY CLAUSE:
RSA 260:14, IX states as follows:
(a) A person is guilty of a class B misdemeanor if such person knowingly discloses information from a department record
to a person known by such person to be an unauthorized person; knowingly makes a false representation to obtain
information from a department record; or knowingly uses such information for any use other than the use authorized by the
department. In addition, any professional or business license issued by this state and held by such person may, upon
conviction and at the discretion of the court, be revoked permanently or suspended. Each such unauthorized disclosure,
unauthorized use or false representation shall be considered a separate offense.
(b) A person is guilty of a class B felony if, in the course of business, such person knowingly sells, rents, offers, or exposes
for sale motor vehicle records to another person in violation of this section.
OFFICIAL USE ONLY
Date Received:_______________________
Date Sent:___________________________
Type of Identification:
Valid Photo Driver License
State-issued Photo ID
Valid Military Identification
Valid Passport
Birth Certificate
Other (specify) __________
ID Number _____________________________________
_______________________________________________
______________________________________
Employee Verifying Applicant Identification (Print Name)
Signature
-----------------------------------------------DO NOT WRITE BELOW THIS LINE----------------------------------------------
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