Dmv Form Ds 19 – Fill Out and Use This PDF

New York State Department of Motor Vehicles

ARTICLE 19-AMOTOR CARRIERACCIDENTAND CONVICTION

NOTIFICATION PROGRAMAPPLICATION

(EscrowAccount & Driver’s Privacy ProtectionAct Compliance)

Article 19-A of the New York State Vehicle and Traffic Law (VTL), Section 509-i(4) requires all motor carriers to establish an escrow account which shall be used to pay for the costs incurred by DMV when it informs the motor carrier of a driver’s conviction or accident.

INSTRUCTIONS:

1.The Carrier must complete all sections on page 1 and page 2 of this form. Pleaseprintclearly.

2.Review the opening deposit table below to determine the required opening escrow deposit amount.

Number of drivers to enroll in the 19-A program	Opening Deposit to send to DMV
0 to 25	$10.00
26 to 65	25.00
66 to 115	40.00
116 to 225	50.00
More than 225	70.00

3.Make your check or money order payable to “Commissioner of Motor Vehicles” (never send cash) and mail it with this completed form to: NYS Department of Motor Vehicles, Bus Driver Unit, 6 Empire State Plaza, Room 136B, Albany, NY 12228.

Motor Carrier Information:

Motor Carrier’s Name: ________________________________________________________________________________________

Address: ____________________________________________________________________________________________________

City: ____________________________________________________ State ___________ Zip Code: ______________________

Federal Employer ID Number (FEIN):			-

Location where the Motor Carrier maintains drivers’ records for audit:

Address: ____________________________________________________________________________________________________

City: _______________________________________________________ State: _________ Zip Code: ________________________

(	)	(	)
Telephone:_____________________________ ext. ________		Fax: (optional) ______________________________ ext. ________

E-Mail: ___________________________________________________________________ (optional)

Person responsible for maintaining the 19-A records of the Motor Carrier’s drivers:

Name:____________________________________________________________________________________________________

Telephone:___________________________( ) ext.________

Person responsible for billing:

Name: __________________________________________________________________________________________________

Address: ________________________________________________________________________________________________

City: _______________________________________________________ State: _________ Zip Code: ____________________

(		)	(	)
	Telephone: ___________________________ ext. ________		Fax: (optional) _____________________________ ext. ________
	E-Mail: _________________________________________________________________ (optional)
	FOR	DMV approval by: (Sign) ➧

DMV OFFICE

DS-19 (10/13)

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The Federal Driver’s Privacy Protection Act (DPPA) (18 USC. Sec. 2721 et seq.) regulates the access, disclosure, and dissemination of personal information contained in motor vehicle records maintained by DMV. DPPA, Section 2721 (b)(14) permits Article 19-A Motor Carriers to gain access to their drivers’ records for the sole purpose complying with state and federal laws governing the carrier’s obligation to protect public safety.

By submitting this application to participate in the Accident and Conviction Notification Program, the undersigned Motor Carrier acknowledges and certifies as follows:

1.The Motor Carrier will only request and use information provided by DMV as specifically authorized under federal and NYS laws, where the requested information is related to the operation of the carrier’s drivers’ motor vehicle records or public safety (DPPA 2721 (b)(14); VTL, Article 19-A - Special requirements for Bus Drivers); the carrier will advise its pertinent personnel of their obligations thereunder, and will ensure that personal information provided by DMV is not accessed, used or disseminated for unauthorized purposes.

2. Informationwhichisprovidedelectronically to the Motor Carrier is also subject to the New York State Information Security Breach and Notification Act (ISBNA) (G.B.L. §899-aa; State Technology Law, §208). DMV is required to notify individuals if their records are accessed for unauthorized purposes. The Motor Carrier must report suspected or confirmed violations of the DPPA or ISBNA to the DMV Information Security Office, within one (1) business day of discovering any such violation, by email to InformationSecurity@dmv.ny.gov, or by telephone at (518) 402-2676. The Motor Carrier shall be responsible for all costs associated with providing notices required under the ISBNA.

3.The Motor Carrier must keep, for a period of 5 years, records identifying each person or entity that receives personal information from DMV, and the date, time and purpose for which the information was used and accessed. The Motor Carrier will cooperate with any audit of such records by DMV or the State. The Motor Carrier must make such records available to DMV for audit purposes. If the Motor Carrier does not have an office location in New York State, it must forward to DMV all records requested, at the time, place and location designated by DMV. The Motor Carrier must promptly notify the DMV in writing of any change of its name, or the physical address where the pertinent records will be maintained.

4.The State shall not be responsible for any omissions or errors in the information furnished to the Motor Carrier by DMV.

5.TheMotorCarriershallindemnify,keepandholdharmlesstheStateofNewYork,itsagents,officialsandemployeesfromany andallclaimsforinjuryordamagetopersonorproperty,deaths,losses,damages,suitsarisingoutofthenegligent,improper,or unauthorizeduseordisseminationbytheMotorCarrier,itsofficers,employeesoragentsofpersonalinformationprovidedbyDMV.

6.In the event of any suspected or confirmed breach of the security of personal information provided by DMV, DMV reserves the right and sole discretion to suspend or terminate the Motor Carrier’s access to personal information from motor vehicle records maintained by DMV.

THE UNDERSIGNED MOTOR CARRIER CERTIFIES UNDER PENALTY OF PERJURY THAT IT HAS READ AND UNDERSTOOD THE FOREGOING AND THAT ALL INFORMATION PROVIDED IN THIS APPLICATION IS TRUE AND ACCURATE.

Carrier’s Name: ________________________________________________________________________________________,

byitsdulyauthorizedrepresentative(Owner/GeneralPartner/dulyauthorizedCorporateOffice/LLCManagingMember/SchoolSuperintendent)

Representative’s Name (Sign) ➧

Print Name:

NOTARY ACKNOWLEDGEMENT:

STATE OF NEW YORK

)

)ss:

COUNTY OF____________________ )

On the _____________ day of ______________________ , in the year 20 ________ , before me personally came

___________________________________________________ , to me known who, being by me duly sworn, did depose and

say that s/he resides in ______________________________________________________________ (county, state); that s/he is the

______________________________ (e.g., president, officer, director, managing member, attorney in-fact) and duly authorized

representative of ____________________________________________________, the business entity (principal) described in and

which executed the above instrument; and that s/he signed his/her name thereto on behalf of said business entity (principal), and within the scope of his/her authority to bind said principal to the terms of the foregoing Agreement.

Notary Public

DS-19 (10/13)

www.dmv.ny.gov

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