Form Bmv 1173 – Fill Out and Use This PDF

OHIO DEPARTMENT OF PUBLIC SAFETY

BUREAU OF MOTOR VEHICLES

OBMV RECORD REQUEST

(Ohio Revised Code [R.C.] 4501.15, 4501.27, AND 4507.53)

This agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under R.C. 4501.27. Disclosure of this information is REQUIRED. FAILURE to provide any information will result in this form not being processed.

This request is being made by (check one):

An individual inquiring regarding himself or herself: (Complete Part A) If inquiring in person for information on yourself, you must provide personal information regarding yourself, or prove your identity by presenting your driver license or identification card.

An individual inquiring regarding another person: (Complete Parts A and B) If inquiring regarding another individual, you must attach a notarized BMV Form 5008 giving the written consent of the person. All mail requests without the BMV Form 5008 attached will be returned to the requester.

Other: (Check applicable reason for request on Part C, and complete Parts A and B)

I am requesting the following personal information contained in the Bureau of Motor Vehicles records:

Driving Record [302]	($5.00)	Copy of Title Record	($5.00)
Last Known Address [405] (Mail in Only)	($5.00)	Vehicle Registration Record [303]	($5.00)
Cosigner w / Date of Loss-_______ [405] (Mail in Only)	($5.00)
Copy of Driver License Application [405A]	($5.00)

	PART A: Please provide current information regarding yourself:			NOTE: SIGNATURE REQUIRED
	YOUR NAME (REQUESTER)	DATE OF BIRTH	SIGNATURE					DATE
			X
	CURRENT STREET ADDRESS		CITY			STATE		ZIP
	COMPANY (IF APPLICABLE)		BMV ACCOUNT # (IF APPLICABLE)
	*SOCIAL SECURITY # (OPTIONAL)		DRIVER LICENSE #		LICENSE PLATE #
	VEHICLE IDENTIFICATION #	TITLE #			TELEPHONE # / FAX #

	PART B: Request regarding other person(s):
	PERSON’S NAME					DATE OF BIRTH
	STREET ADDRESS		CITY			STATE		ZIP
	*SOCIAL SECURITY # (OPTIONAL)		DRIVER LICENSE #			LICENSE PLATE #

If requesting information on more than 1 person or vehicle, attach additional sheet(s).

Additional sheet(s) attached

Make check or money order payable to Ohio Treasurer of State. If mailing, return to: Ohio Bureau of Motor Vehicles, Attn: Records

Request, P.O. Box 16520, Columbus, Ohio 43216-6520. Results will be mailed to requester.

NOTE: When submitting this form in person to the Customer Service Center located at 1970 W. Broad St., Columbus, OH 43223, an additional $3.50 fee will be charged. Additionally, not all record types listed above are available for processing at the Customer Service Center.

*It is not necessary that you provide a Social Security #. However, in order to best assist you with your request, please provide the Ohio BMV with as many identifiers as possible.

Part C: I (requester) qualify as checked below, and I am requesting:

1.As an individual. (Complete Part A, front)

2.A record for use in the normal course of business by me as a legitimate business or an agent, employee, or contractor of a legitimate business, for one of the two following purposes: (a) to verify the accuracy of personal information submitted to the business, agent, employee, or contractor by an individual; (b) in case personal information submitted to the business, agent, employee, or contractor by an individual is incorrect or no longer is correct, to obtain the correct information, for the sole purpose of preventing fraud, by pursuing legal remedies against, or recovering on a debt or security interest against, the individual.

My tax identification number is: My vendor number is:

My professional license number is: Licensed by (agency):

3.With written consent. (Complete Parts A and B, front).

4.Records for bulk distribution for surveys, marketing, or solicitations, where the information will be used, rented, or sold solely for bulk distribution for surveys, marketing, or solicitations;

5.A record for the use of a government agency, including, but not limited to, a court or law enforcement agency, in carrying out its functions, or for the use of a private person or entity acting on behalf of an agency of this state, another state, the United States, or a political subdivision of this state or another state in carrying out its functions (a law enforcement agency does not need to fill out this form);

6.A record for use in connection with matters regarding 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, but not limited to, survey research; and removal of non-owner records from the original owner records of motor vehicle manufacturers. Please provide relevant documentation supporting your request.;

7.A record for use in connection with a civil, criminal, administrative, or arbitral proceeding in a court or agency of this state, another state, the United States, or a political subdivision of this state or another state or before a self-regulatory body, including, but not limited to, use in connection with the service of process, investigation in anticipation of litigation, or the execution or enforcement of a judgment or order (a subpoena or other court order may be used instead of this form). Please provide the court and case number, or if the case has not yet been filed, the court you

anticipate to file in

;

8.A record pursuant to an order of a court of this state, another state, the United States, or a political subdivision of this state or another state (a subpoena or other court order may be used instead of this form). Please attach a certified copy of the court order:

9.Records for use in research activities or in producing statistical reports, where the personal information will not be published, redisclosed, or used to contact an individual. Please provide a detailed description of your research activities and identify the business, educational institution, or other entity for which you are doing the research;

10.Records for use by an insurer, insurance support organization, or self-insured entity, or by an agent, employee, or contractor of that type of entity, in connection with a claims investigation activity, anti-fraud activity, rating, or underwriting. Please provide your Tax Identification, Vendor, or

Professional license number along with the name of the licensing agency:

;

11.A record for use in providing notice to the owner of a towed, impounded, immobilized, or forfeited vehicle. Please provide your Tax

Identification, Vendor, or Professional license number along with the name of the licensing agency:

;

12.A record for use by a licensed private investigative agency or licensed security service for any purpose permitted under numbers 1 through

15 of this form; my agency license number is:

;

13.A record for use by an employer or by the agent or insurer of an employer to obtain or verify information relating to the holder of a commercial driver license or permit that is required under the “Commercial Motor Vehicle Safety Act of 1986”, 100 Stat. 3207-170, 49 U.S.C. 2701, et seq., as now or hereafter amended. Please provide your Tax Identification, Vendor, or Professional license number along with the name of

the licensing agency:

;

14.A record for use in connection with the operation of a private toll transportation facility;

15.A record for any other use specifically authorized by law that is related to the operation of a motor vehicle or to public safety. Please provide a copy of the relevant statute.

16.A record in order to carry out the purposes of either the “Automobile Information Disclosure Act”, 72 Stat. 325, 15 U.S.C. 1231-1233, the “Motor Vehicle Information and Cost Saving Act”, 86 Stat. 947, 15 U.S.C. 1901, et seq., the “National Traffic and Motor Vehicle Safety Act of 1986” 80 Stat. 718, 15 U.S.C. 1381, et seq., the “Anti-Car Theft Act of 1992”, 106 Stat 3384, 15 U.S.C. 2021, et seq., or the “Clean Air Act”, 69 Stat. 322, 42 U.S.C. 7401, et seq., all as now or hereafter amended, for use in connection with one or more of the following matters: (a) motor vehicle or driver safety and theft; (b) motor vehicle emissions; (c) motor vehicle product alterations, recalls, or advisories; (d) performance monitoring of motor vehicles and dealers by motor vehicle manufacturers; (e) removal of non-owner records from the original owner records of motor vehicle manufacturers.

I understand that if I receive personal information under numbers 2, 3, or 5-16 of this form, I may resell or disclose the personal information only for uses permitted under numbers 2, 3, or 5-16. I understand that if I receive personal information under number 2-16 of this form, and I resell or redisclose any personal information, I must keep for a period of five years a record that identifies each person or entity that receives any of the personal information and the permitted purpose for which the information is to be used, and I must make all such records available to the Registrar of Motor Vehicles upon request.

I hereby certify that all of the information contained on this form is true and accurate to the best of my knowledge and belief. I understand that providing false information may constitute a criminal offense of falsification with a maximum penalty of 6 months in jail and a $1000 fine.