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Requestor Information

COMMONWEALTH OF MASSACHUSETTS	For RMV Use Only
REGISTRY OF MOTOR VEHICLES (RMV)	Date:	Initials: ______________
P.O. Box 55889	Date:	Initials: ______________
P.O. Box 55889
Boston, MA 02205-5889	Batch Number: ________________________
	Batch Number: ________________________

REQUEST FOR PERSONAL INFORMATION IN RMV RECORDS

(Use for individual or multiple record requests)

___________________________________________________________		_________________________________________
Name of Requestor		Home Telephone
__________________________________	_______________________	_____________	___________________
Street	City	State	Zip
as an authorized representative of:
_____________________________________________________________		_________________________________________
Name of Company or Firm		Business Telephone
__________________________________	_______________________	_____________	___________________
Street	City	State	Zip

Information Requested

(Please complete as much information as possible.)

I request access to motor vehicle record(s), including personal information as defined in 18 U.S.C. §2725, concerning the following person or persons. (If requesting multiple records, please attach lists of names and identifying information.)

___________________________________________________________________________________________________

Name (Last)(First)(Middle)

_____________________________________________________________________________________________________

Home Address (Street)	(Apt. No.)	(City/State)	(Zip)
____________________________ ______________________________		________________________________
Date of Birth (month/day/year)	Driver's License No.	Social Security No.
____________________________ _____________________________		________________________________
Vehicle Registration No.	Vehicle Title No.	Vehicle Identification (VIN) No.

The Requestor MUST initial the applicable category below.

_____	(1)	The Requestor is an insurance company, or an authorized agent or service carrier, and the records will be used to the
		extent authorized in the Safe Driver Insurance Plan (SDIP) and for the purposes of complying with the requirements
		of M.G.L. Chapter 90, §§ 1A, 34A, 34B, and 34H pertaining to motor vehicle liability policies. Appropriate
		documents identifying Requestor are required. A photocopy of the ID will be made to file with the request.
_____	*(2)	The Requestor is an insurer or insurance support organization, a self-insured entity, or an agent, employee or
		contractor of such and the records will be used in connection with claims investigation activities, anti-fraud
		activities, rating or underwriting. Appropriate documents identifying Requestor are required. A photocopy of the
		ID will be made to file with the request.
_____	*(3)	The Requestor is a federal, state, or local government agency, or a private person or entity acting on behalf of a
		federal, state, or local government agency, and the records will be used to carry out the official functions of such
		federal, state, or local government agency. Appropriate documents identifying Requestor are required. A
		photocopy of the ID will be made to file with the request.
		Name of Agency_________________________________________________ Tel._______________________
		Contact Person __________________________________________________ Tel._______________________
_____	*(4)	For use in connection with a civil, criminal, administrative, or arbitral proceeding in a court or before a government
		agency or self-regulatory body or to effectuate service of process or for use in an investigation in anticipation of
		litigation, or the execution or enforcement of judgements, or orders pursuant to a court order. The Requestor must
		be an attorney or law firm, constable, or licensed private detective, and the professional’s occupational license
		number must be provided. Appropriate documents identifying Requestor are required. A photocopy of the ID will
		be made to file with the request.
		Board of Bar Overseers or License No. ________________________________
T21078-1109		Page 1 of 4

_____ (5) The records will be used in the normal course of business by a legitimate business or its agents, employees, or

contractors, BUT ONLY (i) to verify the accuracy of personal information submitted by the individual to the business or its agents, employees or contractors, and (ii) 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. Appropriate documents identifying Requestor are required. A photocopy of the ID will be made to file with the request.

_____ *(6) The Requestor is an employer or its agent or insurer and the records will be used to obtain or verify information

relating to a holder of a commercial driver’s license that is required under the Commercial Motor Vehicle Safety Act of 1986 (49 U.S.C. App. 2710 et seq.) or M.G.L. Chapter 90F. Appropriate documents identifying Requestor are required. A photocopy of the ID will be made to file with the request.

_____ (7) The records will be made available to law enforcement agencies and towing companies to be used in providing

notice to the owners (including lienholders) of towed or impounded vehicles. Appropriate documents identifying Requestor are required. A photocopy of the ID will be made to file with the request.

_____ (8) The Requestor is a licensed private detective business or licensed watch, guard or patrol agency (which may include a

security service) licensed under the provisions of M.G.L. c. 147, §25, or under the laws of another state, and the records will be used only for one of the permitted uses contained in items 1-12. (The Requestor must indicate the permitted use(s) (by also initialing that category) and produce a valid and unexpired professional license assigned by the Colonel of the Massachusetts State Police or by the licensing official of the state where licensed.) Appropriate documents identifying Requestor are required. A photocopy of the ID will be made to file with the request.

License No. must be provided: ________________________

_____ (9) The Requestor has obtained the notarized, express written consent of the individual to whom the information relates

to obtain such information. (Original notarized Voluntary Consent from the individual to whom the information relates must accompany the completed Request.) Appropriate documents identifying Requestor are required. A photocopy of the ID will be made to file with the request.

_____ (10) The records will be used in connection with matters of motor vehicle or driver safety and theft, motor vehicle

emissions, product alterations, recalls or advisories, performance monitoring of motor vehicles, motor vehicle parts or dealers, motor vehicles market research activities or survey research, or removal of non-owner records from the original owner records of a motor vehicle manufacturer. A written explanation detailing the reasons why you believe you qualify within this category must be attached to this document. Appropriate documents identifying Requestor are required. A photocopy of the ID will be made to file with the request.

_____ (11) The records will be used in research activities and for use in producing statistical reports, provided that any personal

information shall not be published, re-disclosed, or used to contact the individual. A written explanation detailing the reasons why you believe you qualify within this category must be attached to this document. Appropriate documents identifying Requestor are required. A photocopy of the ID will be made to file with the request.

_____ (12) For any other use specifically authorized under state law, if such use is related to the operation of a motor vehicle or

public safety. A written explanation detailing the reasons why you believe you qualify within this category must be attached to this document. Appropriate documents identifying Requestor are required. A photocopy of the ID will be made to file with the request.

*By law, express written consent from the individual to whom the information relates is not required from the Requestors in these categories for social security numbers. However, even these Requestors may not obtain photoimages, or medical or disability information without the notarized, express written consent of the person to whom the information pertains or by judicial order.

Penalty: 18 USC § 2723 provides that anyone who knowingly obtains, discloses, or uses personal information from a motor vehicle record for a purpose not permitted under 18 U.S.C. §2721, shall be liable to the individual to whom the personal information pertains, including an award of the greater of actual damages or liquidated damages of two thousand five hundred dollars for each violation, punitive damages upon proof of willful or reckless disregard of the law, reasonable attorneys fees and other litigation costs, and such other equitable relief as the court may order. Anyone requesting the disclosure of personal information who misrepresents his identity or makes a false statement in connection with any request for personal information with the intent to obtain personal information in a manner not authorized by law shall be subject to criminal prosecution, which may include a fine of not more than five thousand dollars or imprisonment in a jail or house of correction for not more than one year, or both.

T21078-1109

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T21078-1109

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If you are requesting the information by mail . . .

1) Provide as much information as possible on this form so the RMV can properly search your request.

2) Include the correct payment.

3) Mail your request to:Massachusetts Registry of Motor Vehicles P.O. Box 55889

Boston, MA 02205-5889

Attn: Court Records (for certified records only) or

Attn: Mail Listings (for all other requests)

Please remember to . . .

1) Enclose a photocopy of your driver’s license, state issued ID card, or a valid professional license. (Your request cannot be processed without proper identification.)

2) Enclose a check or money order payable to “MassDOT.”

(The fee is $20.00 for each certified driving record. Amounts due for other records may vary. Please call the Customer Assistance Bureau at 617-351-9580.)

THANK YOU!

________________________________________

RMV Employee Name (Print)

________________________________________________________

RMV Employee Signature

Identification provided by Requestor: (Describe ID document provided and its source, e.g., Delaware driver license no. D123456789; State

of Michigan ID., etc.) Note: A photo ID/license is preferred.

_______________________________________________________________________________________________________

Check here if no records were found. Do not charge customer.

_______________________________________________________________________________________________________

Date sent: ____________________

RMV USE ONLY:

Date received: ____________________

___________________________________________________

Requestor's Signature

CERTIFICATION OF REQUESTOR - READ CAREFULLY

The Requestor certifies that all Registry of Motor Vehicles records obtained by the Requestor will be used solely and exclusively for the purposes indicated in this certification, and for no other purpose. The Requestor shall be responsible for any improper or unauthorized access to or use of motor vehicle records by any of its employees, servants, agents or contractors. The Requestor is prohibited from re-disclosing the information, except in accordance with applicable law. The Requestor acknowledges that the Registry of Motor Vehicles is relying on the truth of the representations contained in this certification in granting the Requestor access to personal information contained in the Registry's motor vehicles records, and the Requestor intends that the Registry so rely. The Requestor acknowledges that it must keep, for a period of five (5) years, records identifying each person it has sought information about and the permitted purpose for which the information was sought. The Requestor agrees to make such records available to the RMV upon request. The Requestor agrees to indemnify the Commonwealth of Massachusetts, its agents, officers and employees with respect to any claims asserted by an individual whose personal information was disclosed to the Requestor in reliance upon the representations made herein and the Requestor further agrees to hold harmless the Commonwealth of Massachusetts, its agents, officers and employees with respect to any claims the Requestor may have as to the accuracy of the information provided.

This certification is signed under the penalties of perjury this	day of	, 200_______

Voluntary Consent for Release of “Highly Restricted Personal Information” From the Records of the Massachusetts Registry of Motor Vehicles (RMV)

The provisions of the Federal Driver Privacy Protection Act, as amended, 18 U.S.C. §2721 et seq., govern the release of personal information from the Massachusetts Registry of Motor Vehicles. The four types of information listed below are considered to be “highly restricted personal information” under that law and may not be released to most requestors of information without the notarized written consent of the person to whom the information relates. (Four categories of Requestors may obtain the Social Security Number without the consent of the individual. For information on who may obtain information from the RMV and the types of information they may obtain, visit the RMV web site at www.mass.gov/rmv or call the RMV Telephone Center at 617-351-4500 and request a copy of FAQs on Driver License Privacy in Massachusetts.)

I, _____________________________________________	____/____/____	____-______-_____
Print Your Name as it Appears on your Driver’s License/ID Card, etc.	Date of Birth.		Telephone No:
	(Month-Day-Year)
_________________________________________ _____________________		______	_______________
Street Address	City/Town	State	Zip Code

hereby authorize the Massachusetts Registry of Motor Vehicles (RMV) to release to:

_______________________________________________________________________________________

(Name of Requestor)

the “highly restricted personal information” listed below relating to me, which I have consented to release by my signature, and which the RMV may have in its motor vehicle records. I agree to hold harmless the Commonwealth of Massachusetts and its agents, officers and employees for the release of the authorized

information. (Sign only for the Record(s) you wish to release.)

Soc. Sec. No. (SSN)

(Signature)

Photoimage ________________________________

(Signature)

Medical Records____________________________

(Signature)

Disability Records___________________________

(Signature)

The signature(s) of the person providing consent is required to be notarized.

Today’s Date ______________________________

Notarization

On this _______ day of ______________________, ________, before me, the undersigned notary public,

personally appeared ___________________________ (name of document signer,) proved to me through

satisfactory evidence of identification, which were ___________________________ to be the person whose

name is signed above, and acknowledged to me that he/she signed it voluntarily for its stated purpose.

	Signature of Notary Public

Place notary seal above.	My Commission Expires

T21078-1109	Page 4 of 4

Question	Answer
Form Name	Form T21078 1109
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	21078 request for personal information in rmv records

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