Form Mv 15D – Fill Out and Use This PDF

uIf you are opening a new account for a commercial or not-for-profit organization, attach an opening deposit.The deposit amount should fund your estimated usage for two months. Electronic searches are $7 each. Mail order searches are $10 or more, depending on what kinds of certified documents you request. Please make your check or money order payable to “Commissioner of MotorVehicles”.

and you will be using the information obtained for a public purpose, complete the Fee Exemption Certification on page 4 to claim the exemption from search fees under Section 202 of the New York State Vehicle and Traffic Law.

You must also provide evidence of your government employment or your affiliation with the exempt organization, such as a pay stub or an official letter from the organization.

uIf you represent a commercial or not-for-profit organization (including volunteer fire companies and volunteer ambulance services), include a certified copy of your business certificate.

uSend the form to: DATA SERVICES - NEW SEARCH ACCOUNT

NYS DEPARTMENT OF MOTOR VEHICLES 6 EMPIRE STATE PLAZA

ALBANY NY 12228

ACCOUNT INFORMATION

(Please Print or Type)

Please mark one of the following boxes to indicate which service you are requesting:

Open new account

Update information for an existing account. DMVwill need your account number to process any changes.

ACCOUNT #:_____________________________

Applicant: ________________________________________________________________________________________

Applicant’s Driver License Number: _________ - _________ - _________ State/Province:______________________

Organization: ______________________________________________________________________________________

Address:__________________________________________________________________________________________

(DO NOT GIVE P.O. BOX)

City: __________________________________________________ State:_________ Zip Code:____________________

Telephone: _______ - _______ - __________ Ext. ____________ Fax: _______ - _______- __________

EmailAddress:____________________________________________________________________________________

Federal Employer ID Number:

Please describe in detail how you plan to use the information from searches of DMV’s records:

If DMV has ever terminated a search account held by you, your organization, or any principal, agent, officer or employee associated with your organization, please provide the account number(s):

_________________________________________________________________________________________________

MV-15D (8/13)

www.dmv.ny.gov

PAGE 1 OF 4

CERTIFICATION OF PERMISSIBLE USES

The Federal Driver's Privacy Protection Act (18 U.S.C. §2721.et seq.) (“DPPA”) regulates access to Motor Vehicle records. RecipientherebycertifiesthattheinformationprovidedhereunderbyDMVshallbeusedsolelyforthefollowingpurpose(s).

(Recipient must check all that apply)

1.___ Usebyanygovernmentagencyincludinganycourtorlawenforcementagency,incarryingoutitsfunctions.(18U.S.C.§2721(b)(14))

2.___ Use by any private person or entity acting on behalf of a federal, state, or local agency in carrying out its functions.

(18U.S.C.§2721(b)(1))

3.___ Use in matters of motor vehicle or driver safety. (18U.S.C.§272(b)(2))

4.___ Use in matters of motor vehicle theft. (18U.S.C.§2721(b)(2))

5.___ Use in matters of motor vehicle emissions. (18U.S.C.§2721(b)(2))

6.___ Use in matters of motor vehicle product alterations, recalls or advisories. (18U.S.C.§2721(b)(2))

7.___ Use in performance monitoring of motor vehicles, motor vehicle parts and dealers. (18U.S.C.§2721(b)(2))

8.___ Use in motor vehicle market research activities, including survey research (18U.S.C.§2721(b)(2))

9.___ Use in removal of non-owner records from the original owner records of motor vehicle manufacturers. (18U.S.C.§2721(b)(2))

10.___ For use in the normal course of business by a legitimate business or its agents, employees, or contractors, but only-

(A)to verify the accuracy of personal information submitted by the individual to the business or its agents, employees, or contractors; (18 U.S.C. §2721 (b)(3)(A)) and

(B)if such information as so submitted is not correct or is no longer correct, to obtain the correct information, but only for the purposes of preventing fraud by, pursuing legal remedies against, or recovering on a debt or security interest against, the individual. (18 U.S.C. §2721 (b)(3)(B))

11.___ Use in any civil, criminal, administrative, or arbitral proceeding in any court or agency, including the service of process, investigation inanticipationoflitigation,andtheexecutionorenforcementofjudgmentsandorders,orpursuanttoacourtorder.(18U.S.C.§2721(b)(4))

12.___ Use by an insurer or insurance support organization or self-insured entity in claims investigations, anti-fraud activities, rating or underwriting activities. (18U.S.C.§2721(b)(6))

13.___ Use in providing notice to the owners of towed or impounded vehicles.(18U.S.C.§2721(b)(7))

14.___ Use by an employer, its agent or insurer to obtain information relating to the holder of a commercial driver license required under Chapter 313 of Title 49 of the U.S.C.) (18U.S.C.§2721(b)(9))

15.___ Use in the operation of private toll transportation facilities. (18U.S.C.§2721(b)(10))

16.___ Use by any requester, if the requester demonstrates it has obtained the written consent of the individual to whom the information pertains. (May use form MV-25GC)(18U.S.C.§2721(b)(13))

17.___ Use required under NYS Vehicle and Traffic Law, Article 19-A — Special Requirements for Bus Drivers. (18U.S.C.§2721(b)(14))

18.___ Use required under NYS Vehicle and Traffic Law, Article 19-B — Special Requirements for Commercial Motor Carriers.

(18U.S.C.§2721(b)(14))

19.___ Use specifically authorized under NYS law, IF such use is related to the operation of a motor vehicle or public safety. Cite the specific NYS law here: ___________________________________________________ (18U.S.C.§2721(b)(14))

To knowingly make a false statement or conceal a material fact in this written statement is a criminal offense, punishable under Penal Law Section 210.45. In addition, anyone who makes false representation to obtain any personal information from an individual’s Motor Vehicles record is subject to federal criminal fines under the Driver’s Privacy Protection Act (DPPA).

MV-15D (8/13)

PAGE 2 OF 4

TERMS OF SERVICE

1.You will perform searches of DMVrecords only when one of the permissible uses that you initialed on page 2 arises.You agree not to perform searches of DMVrecords for the purposes described in 18 USC Sec 2721(b)(5), (11), and/or (12). Under the New York State Information Security Breach and NotificationAct, DMVis required to notify individuals if their records are accessed for unauthorized purposes.

2.You will notify DMV in writing, within 30 days, if there is any change in the information you have provided in this application. You will file a replacement for this application within 60 days of any request by DMV to do so.

3.You will maintain business records documenting the purpose of each search and identifying the individual who performed the search.You will maintain each record FOR FIVEYEARS after the date of your search.The records must be available to DMV, upon request, for audit purposes.At DMV’s direction, you will forward the records to DMVor you will make the records available for inspection at your place of business.The records must be organized to permit retrieval by the name, license number, plate number orVIN for which you searched. If you do not maintain an office location within NewYork State, you may be asked to forward all records requested to a place and location designated by the Department.The location where you will keep records of searches is:

Address: ____________________________________________________________________________________

City: ___________________________________________ State: _______ Zip Code:______________________

Contact Person: ______________________________________________________________________________

Telephone: _______ - _______ - _________ Ext. __________ Fax: _______ - _______- _________

EmailAddress: _____________________________________________________________________________

4.If you share personal information from DMVwith a recipient outside your organization, you will collect from that recipient an agreement identifying the recipient and specifying their DPPAPermissible Use for the information. You will retain the agreement FOR FIVEYEARS after the date when you last shared DMVrecords information with the recipient.You will make the agreement available to DMVfor audit purposes.

5.You will not represent yourself as an agent or employee of the DMV.

6.You will defend, indemnify and hold harmless the DMVand its employees or agents from all claims, actions, damages, or losses, including the cost of any notifications required under the New York State Information Security Breach and NotificationAct, arising from your negligent, improper, or unauthorized use or dissemination of information contained in DMVrecords.

7.NewYork State will not be responsible for any omissions or errors in the information furnished to you.

8.Youacknowledgethatallrecordsofsearchesplacedbyyouarepublicrecords,andmaybemadeavailabletoanyparty.

9.The DMVreserves the right to terminate access to your account at anytime, in its sole discretion, and without advance notice. Reasons for termination include but are not limited to: false statements made by you; concealment of material facts in connection with this application; and violation of any of the terms of service.

10.This agreement is not transferable.

MV-15D (8/13)

PAGE 3 OF 4

ACKNOWLEDGEMENT OF TERMS OF SERVICE

I certify that I have read, understood, and will comply with the DPPA, and the Terms of Service for use of the search account.

Signature ofApplicant: ____________________________________________________

Date: ________________

(Signinthepresenceofanotary)

FEE EXEMPTION CERTIFICATION

FOR GOVERNMENT ORGANIZATIONS, VOLUNTEER FIRE COMPANIES, VOLUNTEERAMBULANCE SERVICES,AND ENTITIESACTING PURSUANT TO SECTION 722 OF THE NEW YORK STATE COUNTY LAW ONLY

Section 202 of the NewYork State Vehicle and Traffic Law exempts government organizations, volunteer fire companies, and volunteer ambulance services from fees for searches and documents to be used for a public purpose, and also exempts legal aid bureaus and societies and other private entities from such fees when acting pursuant to Section 722 of the New York State County Law. I certify that my organization qualifies for this exemption, and that I will use this account only for qualified fee-exempt purposes.

Signature ofApplicant: ____________________________________________________

Date: ________________

(Signinthepresenceofanotary)

TO BE COMPLETED BY NOTARY

STATE OF _____________ }

}ss:

COUNTYOF _____________ }

On the _________ day of _______________ in the year 20____ before me, the undersigned, a Notary Public in and for

said State, ________________ personally appeared __________________________________, personally known to me

or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the

within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies), and that by

his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted,

executed the instrument.

____________________________________________

Notary

MV-15D (8/13)

PAGE 4 OF 4