Form 4678 – Fill Out and Use This PDF

INSTRUCTIONS: This form must be fully completed and approved before a Requester can obtain access to restricted information. Only Requesters who meet the criteria outlined in Section B are eligible to obtain restricted information and a security access code.

REQUESTING:

New Security Access Code (first time)

Modify Information

Recertification

SECTION A. REQUESTER INFORMATION

NAME OF INDIVIDUAL OR ORGANIZATION

Check one:

Individual

Partnership

Corporation

LLC

News Media

Government Agency

ALL PERSONNEL AUTHORIZED TO REQUEST INFORMATION:

CHECK AND ATTACH LIST IF NECESSARY

E-MAIL ADDRESS (REQUIRED FOR FUTURE NOTIFICATIONS)

TELEPHONE NUMBER

FAX NUMBER

(__ __ __) __ __ __ - __ __ __ __

(__ __ __) __ __ __ - __ __ __ __

STREET ADDRESS (PHYSICAL LOCATION)

CITY

STATE

ZIP CODE

__ __ __ __ __

MAILING ADDRESS (IF DIFFERENT)

CITY

STATE

ZIP CODE

__ __ __ __ __

SECTION B. PURPOSE OF REQUEST

Requester hereby certifies to the Missouri Department of Revenue (Department) that this request for Missouri motor vehicle or driver license records or information is made under the provisions of the federal Driver’s Privacy Protection Act (DPPA) and Missouri law.

DO YOU PLAN ON RESELLING THE INFORMATION? Yes No IF SO, PLEASE PROVIDE THE METHOD USED TO SELL THE INFORMATION AND ANY ASSOCIATED WEB SITES.

Please carefully review and check all boxes that apply to Requester’s request for access to personal information on a restricted record. Requester is seeking information:

(01) As a government agency (federal, state, or local) or on behalf of a government agency, in carrying out its government functions. (02) As a court (federal, state, or local) or on behalf of a court, in carrying out its court functions.

(03) As a law enforcement agency (federal, state, or local) or on behalf of a law enforcement agency, in carrying out its law enforcement functions.

(04) For use in connection with matters of motor vehicle or driver safety and theft; motor vehicle emissions, motor vehicle product alterations, recalls, or advisories; performance monitoring of motor vehicles, motor vehicle parts and dealers; motor vehicle market research activities, including survey research; and removal of non-owner records from the original owner records of motor vehicle manufacturers.

(05) For use as a legitimate business only (a) to verify the accuracy of personal information submitted by an individual to the business or its agents, employees, or contractors and (b) if such information is not correct, to obtain the correct information, but only for the purposes of preventing fraud by pursuing legal remedies, or recovering on a debt or security interest, against the individual. (For individual requests only.)

(06) For use in connection with any civil, criminal, administrative, or arbitral proceeding in any federal, state, or local court or agency or before any self-regulatory body, including the service of process, investigation in anticipation of litigation, and the execution or enforcement of judgments and orders, or pursuant to an order of a federal, state, or local court.

(07) For use in research activities, and producing statistical reports, so long as the personal information is not published, redisclosed, or used to contact individuals.

(08) As an insurer, insurance support organization, or self-insured entity for use in connection with claims investigation activities, anti-fraud activities, rating or underwriting.

(09) For use in providing notice to the owners of towed or impounded vehicles.

(10) For use by a licensed private investigative agency or licensed security service for a purpose permitted herein.

(11) For use as an employer, its agent or insurer in obtaining or verifying motor vehicle or driver record information relating to a holder of a commercial driver’s license (CDL).

(12) For use in the operation of a private toll transportation facility.

(13) To disseminate to the public in a newspaper, book, magazine, broadcast, or similar form of public communication, when such dissemination is related to the operation of a motor vehicle or to public safety.

For more information, visit www.dor.mo.gov.

DOR-4678 (01-2014)

Has Requester, or any partner, officer or member thereof, ever had, or currently have, a Missouri Security Access Code for the purpose of accessing restricted information?

Yes	No If yes, indicate the current or prior Security Access number or requester code(s): ______________________________

SECTION D. GENERAL SECURITY REQUIREMENTS AND TERMS OF ACCESS. REQUESTER UNDERSTANDS AND AGREES AS FOLLOWS:

1.Requester shall maintain the security and integrity of the information received. A violation of DPPA or of any provision set forth herein, whether by omission or commission, shall be grounds for action by the Department and may result in termination of the security access code.

2.Requester shall ensure compliance with all security provisions set forth herein. If non-compliance is suspected or confirmed, the Requester shall immediately notify the Department by telephone at (573) 751-2633. Requester shall prepare and submit within three business days a written notification of any such non-compliance to the Department at the following address: MISSOURI DEPARTMENT OF REVENUE, GENERAL COUNSEL, PO BOX 475, JEFFERSON CITY, MO 65105-0475.

3.Requester shall maintain a current list of persons and entities authorized to access Department record information, or to whom such information may be disclosed. This list shall be available to the Department upon request.

4.Requester shall not use, sell, retain, distribute, provide, or transfer any restricted record information or portion of such information accessed except as authorized by the Department and as set forth in the DPPA and Missouri law.

5.If Requester resells or discloses personal information covered by the DPPA, Requester must ensure that all recipients of the requested records are authorized under the DPPA and the recipients understand their responsibilities under DPPA. Requester must keep, for a period of five years, records identifying each person or entity that receives such information and the permitted purpose for which the information is to be used, and must make such records available to the Department upon request.

6.Requester understands that Section 302.183.2, RSMo, prohibits the sale of data derived from a person’s driver’s license application for commercial purposes, which includes purposes motivated primarily by financial gain such as, but not limited to, surveys, marketing or solicitations, without the express consent of the person to whom such information pertains. Requester shall not sell personal information for commercial purposes without such consent.

7.The Department reserves the right to audit Requester’s compliance with DPPA. Any such audit shall be performed at reasonable times and in a reasonable manner as determined by the Department.

8.Requester shall not disclose its Department assigned security access code to anyone other than a Department representative or an authorized individual who is in the direct employ of Requester.

9.Requester understands that false or misleading statements herein are cause for denial or termination of any access request. Requester authorizes the Director of Revenue, or the Director’s designee, to investigate any matter or statement contained in this request.

10Requester understands that according to provisions of the Missouri Revised Statutes and the DPPA, any person holding a security access code who directly or indirectly obtains information from the Department using false representations or distributes restricted or confidential information to any person or uses the information for a reason not authorized or specified in this request is liable, subject to penalty, and may be denied further access.

11.Requester understands that if this request is approved, authorization for DPPA access shall be for a term of one (1) year, commencing the day and year the security access code is activated, unless otherwise terminated at the sole discretion of the Department. Requester further understands that this authorization may be renewed for successive one (1) year term(s) upon further request and upon approval by the Department.

12.Requester understands and agrees that the Department shall not be liable for any damages, including but not limited to actual, direct, incidental or consequential damages, arising out of or in any way connected with Requester’s access or use of motor vehicle or driver license record information and that Requester shall indemnify and hold harmless the Department from any claim, loss, cost or expense, including attorney fees, in relation thereto.

Requester certifies under penalty of perjury that: 1) Requester understands and agrees with each and every statement set forth in this request; 2) all information provided in this request is true and correct; and 3) the willful and unauthorized access, use or disclosure of information obtained from any Department record may result in award of damages under Title 18 U.S.C. Section 2724, and imposition of penalties as otherwise provided by law.

SIGNATURE(S) OF INDIVIDUAL, PARTNERS (ALL REQUIRED), AUTHORIZED MEMBER OR CORPORATE OFFICER, NEWS AGENT, OR GOVERNMENT AGENT

PRINTED NAME(S)

TITLE OF CORPORATE OFFICER, NEWS AGENT, OR GOVERNMENT AGENT

NOTARY PUBLIC NAME (TYPED OR PRINTED)

DOR-4678 (01-2014)