Dr 057 Mva Form – Fill Out and Use This PDF

DR-057 (02-19)

My signature acknowledges, under penalty of criminal prosecution, that I will use information received from the Motor Vehicle Administration (MVA) solely for the purpose I describe on this application, and further agree that I will not release personal information obtained from MVA records except as permitted by Title 4 of the General Provisions Article (Maryland Public Information Act).

I understand and acknowledge that by requesting information from Motor Vehicle Administration records I have read and agree to the terms of the MVA Privacy Protection Agreement on the reverse side of this form. I also acknowledge that I have read the Notice of Appeal Procedure also set forth on the reverse side.

Signature: _________________________________________ Printed name: ______________________________________ Date: _______________________

MVA Use Only: ❒ Certified ❒ Non-Certified ❒ Cash ❒ Check ❒ Credit Card ❒ Gratis

6601 Ritchie Highway, N.E., Glen Burnie, Maryland 21062

For more information visit our website at www.mva.maryland.gov, call 410-768-7000 or TTY for the hearing impaired: 1-800-492-4575.

MVA Privacy Protection Agreement

Use of information obtained through this Request is governed by Federal and State laws. It is the responsibility of the Requestor to insure that all use of information obtained through this Request complies with all applicable Federal and State laws.

By signing this “Request for Motor Vehicle Records”, the Requestor certifies that the Requestor, (if applicable) Requestor’s employer and employees:

1.Understand that federal laws affect access to and use of computer information, including, but not limited to, 15 U.S.C. § 271

et seq. (National Institute of Standards and Technology); 44 U.S.C. § 3541 et seq. (Federal Information Security Management Act of 2002); 49 U.S.C. § 30301 et seq. (National Driver Register Act of 1982); 5 U.S.C. § 552 (Freedom of Information Act);

5 U.S.C. § 552a (Privacy Act of 1974); 18 U.S.C. § 1030 (U.S. Computer Crime Statute of 1984); 18 U.S.C. § 1001 et seq. (Computer Fraud and Abuse Act of 1986); 17 U.S.C. § 109 (Computer Software Rental Amendments Act of 1990); 15 U.S.C. § 1681 et seq. (Fair Credit Reporting Act); and 18 U.S.C. § 2721 et seq. (Driver’s Privacy Protection Act of 1994).

2.Understand that the Maryland Department of Transportation Office of Transportation Technology Services, its client agencies and their customers also adhere to State data processing security policies as set forth in Executive Order 01.01.1983.18 (Privacy and State Data System Security); Md. Code Ann., Criminal Law Article § 8-606 (Making false entries in public records and related crimes) and § 7-302 (Unauthorized access to computers and related material); Md. Code Ann., General Provisions Article, Title 4 (Maryland Public Information Act); and, as published by the Secretary of the Department of Budget and Management from time to time under Md. Code Ann., State Finance and Procurement Article, Title 3A, Subtitle 3 (Information Processing).

3.Agree to maintain in strictest confidence and not unlawfully disclose to any person, firm, or corporation information obtained as a result of their access to personal information from motor vehicle records.

4.Are familiar with all provisions of the federal Driver’s Privacy Protection Act of 1994, 18 U.S.C. § 2721 et seq., and with Title 4 of the General Provisions Article (Maryland Public Information Act), and §§ 12-111 through 12-113 of the Transportation Article, Annotated Code of Maryland, which limit access to personal information from public records in Maryland. The Requestor on behalf of itself, its successors and assigns further agrees that all users will abide by the terms of both the federal and state law including, but not limited to, those restricting access to personal information from Motor Vehicle Administration records only to those persons and for those purposes which are permitted under both laws.

5.Agree to keep a record for five (5) years of persons to whom personal information is redisclosed under this Agreement, and the purpose for which the personal information is to be used; and, to make that record available to the Motor Vehicle Administration upon request.

6.Shall be liable for, and shall indemnify, defend and hold the Motor Vehicle Administration harmless for any misuse or misappropriation of any personal information in a record obtained from the Administration in connection with this Agreement, including, without limitation, reasonable attorneys’ fees and all other costs of litigation.

7.Shall further indemnify the Motor Vehicle Administration for and against any and all losses, damages, judgments, liabilities, or similar costs and expenses which arise in whole or part out of acts or omissions by the client with respect to laws restricting access to and disclosure of vehicle records including, without limitation, reasonable attorneys’ fees and all other costs of defending against such action or claim.

Notice of Appeal Procedure

In accordance with General Provisions Article (“GP”) § 4-203(c), the Requestor (“You” or “you”) is informed of all available remedies for review of the decision of the Motor Vehicle Administration (“MVA”) to withhold any of the documents requested on the front side of this form. You have the right/option to refer your concerns to the Public Access Ombudsman, in the Office of the Attorney

General, pursuant to GP § 4-1B-01, et. seq. You may also pursue judicial enforcement under GP § 4-362 of the Maryland Public Information Act. (Copies of the law available upon request.)

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