Fillable Application To Request A Motor Vehicle Account (Page 2 of 2) in pdf

TC-895_2

Application to Request a Motor Vehicle Account

Terms and Conditions

Please read these terms and conditions carefully

before signing and submitting your application.

The Utah State Tax Commission reserves the right to notify the

3. Maintenance of Records and Audit: The Applicant or Adminis-

individual about whom protected information is requested.

trator agrees to take such steps necessary to ensure the privacy

of the records disclosed under this application. Such steps

As a condition of the disclosure of protected records, the Applicant

include instructions and directions that may be provided by the

expressly agrees to the following terms:

Division, the marking of all records as “confidential not to be

1. Responsibility: The Applicant assumes all responsibility for the

copied” and the maintenance of written documentation substan-

protected records of the Division that may be disclosed pursuant

tiating the basis for the access of each record. For example, if

to this application in accordance with Utah Code Ann. Section

access is made to verify the ownership of a vehicle based upon

41-1a-116, 63G-2-202 and the Federal Driver's Privacy Protec-

information supplied by the owner, the Applicant should have in

tion Act, Title 18, Section 2721.

its records an application, statement or consent signed by the

owner representing his or her interest in the subject vehicle.

2. Training: The Applicant agrees to designate an account adminis-

trator to perform all training required by the Division and to

The Applicant agrees to permit the Division reasonable access

ensure the access of all protected records is made in accordance

to all files or documentation pertaining to a disclosed record.

with this application.

Such access may be on an individual basis, such as an investi-

gation of a complaint, or an audit to determine the Applicant’s

The Applicant or Administrator agrees to notify the Division

compliance with the applicable laws and procedures of the

of any change in the designated administrator and/or

Division.

authorized individuals that will utilize this access within 10

business days from such change. Changes must be on

4. Limited Use of Records: The Applicant warrants and

agency letterhead and signed by the Applicant or Administrator.

represents the protected records of the Division will only be

You may fax these changes to: (801) 297-7697, Attn: Third Party

accessed for the purpose marked on this application and that

Representative; or email dmvtlrsearch@utah.gov.

such records will not be used, disclosed or disseminated for any

other purpose, including advertising or solicitation purposes in

The Applicant or Administrator agrees to submit the names of all

any form. The Applicant understands that the improper use,

employees that will be utilizing the DMV Information Account with

disclosure, or dissemination of records accessed under this

this application. The Applicant or Administrator agrees to

application may violate applicable law and result in criminal

notify the Division in writing of any changes to the list of

sanctions and civil liability.

employees within 10 business days of such change. Chang-

es must be on business letterhead and signed by the Applicant or

5. Indemnification: The Applicant assumes responsibility for the

Administrator. You may fax these changes to: (801) 297-7697,

records disclosed and agrees to indemnify and hold harmless

Attn: Third Party Representative; or email

the Division from any and all claims, demands, actions or

dmvtlrsearch@utah.gov.

liabilities that may arise against the Division by reason of the

violation of the aforementioned statutes.

The Administrator will conduct any and all training of its employ-

ees and agents as directed by the Division. It is anticipated that

6. Termination: This application and the Applicant’s access to

training will be required on an annual basis or more frequently

records of the Division may be terminated and denied for any

depending upon the needs of the Division.

reason and at the sole discretion of the Division.

The Administrator shall require all employees, prior to access to

the protected records, to execute an acknowledgment that states

substantially as follows:

I understand that access to DMV records may only be made in

connection with a legitimate business need of the business as

permitted by law. Access of records for an improper purpose,

including personal reasons, is prohibited and subject to penalties

imposed by law. I am responsible for all IDs and passwords

issued to me and will protect them from unauthorized use. If I

learn of any improper use or disclosure of records, I shall report

such use or disclosure immediately to my supervisor and DMV.

_ _ __ __ __ _ __ _ _ _ __ ___ ___ __ ___ _______ ________________________

Applicant name (print)

Title

_ _ __ __ __ _ __ _ _ _ __ ___ ___ __ ___ _______ ________________________

Applicant signature

Date

_ _ __ __ __ _ __ _ _ _ __ ___ ___ __ ___ _______ ________________________ _ __ __ __ _

Designated administrator name (print) *must be filled out and signed

Designated administrator signature

Date

Please allow seven working days for review and processing of your application. You will be notified by mail that your application

has been approved or denied, or if more information is needed.

Provide names of those individuals who will be utilizing your motor vehicle account below.

_ _ __ __ __ _ __ _ _ _ __ ___ ___ __ ___ __________________________________ __ __ __

Application To Request A Motor Vehicle Account Page 2

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