Form Ta Vg 116 D – Fill Out and Use This PDF

State of Vermont	www.dmv.state.vt.us
DEPARTMENT OF MOTOR VEHICLES	[Phone] 802-828-2000
120 State Street	[Fax] 802-828-2098
Montpelier, VT 05603-0001	[TTD] 800-253-0191

VERMONT DMV RECORD REQUEST

Requests for Vermont Department of Motor Vehicles records must be submitted on this form. This form may be photocopied for your convenience. The form must be completed in ink. Please print all information, except signatures, which must be written.

* ALL APPLICABLE SECTIONS OF THIS FORM (FRONT AND BACK) MUST BE COMPLETED TO OBTAIN THE REQUESTED INFORMATION. *

Signature Required on Back of Form

Requester Name:

D.B.A./Company:

Street/Box Number:

Telephone #:

City:

State:

Zip Code:

Mail to (if different than mailing):

Listings of 1 through 4 current or expired registrations - $6.00

Certified copy of suspension notice - $6.00

Certified copy of current or original registration application - $6.00

Certified copy of vehicle title search, title info, lien info. - $20.00

Listing of 1 through 4 current or expired operator’s license - $6.00

Certified copy of vessel, snowmobile or ATV title search - $13.00

Certified copy of expired operator’s license application - $6.00

Insurance information of accident - $6.00

Periodic inspection sticker record - $6.00

Certified copy of 3 year operating record (Vermont only) - $10.00

Statistics and research - $35.00 per hour

Certified copy of complete operating record (Vermont only) - $16.00

Lists of registered dealers, transporters, periodic inspection stations,

Certified copy of reinstatement notice - $6.00

rental vehicle companies, fuel dealers and distributors (including

Certified copy of proof of mailing - $6.00

gallons sold or delivered) - $6.00 per page

Certified copy individual accident report - $10.00

Certified copy of mail receipt - $6.00

Certified copy police accident report - $15.00

Certified copy of title - $6.00

Other – Write explanation on reverse side of this form. All other items of information requested will be furnished at a minimum charge of $4.00.

	DO NOT MAIL CASH.	MAKE CHECK OR MONEY ORDER PAYABLE (IN U.S. FUNDS ONLY) TO: VT DEPARTMENT OF MOTOR VEHICLES.
		FOR DEPARTMENT USE ONLY

Audit Line:

I am requesting information concerning:

VIN Number

Vehicle Make

Vehicle Year

VT License Plate Number

Name

VT Driver License Number

Date of Birth

Street/Box Number

Social Security Number

City

State

Zip Code

Date(s) you want covered, if applicable (does not apply to driving records)

Month

Day

Year

Through

Month

Day

Year

AUTHORIZATION OF RELEASE OF INFORMATION

I hereby, with my signature, authorize (print name of person or business you are authorizing):

To perform a one-time search of the VT Department of Motor Vehicles files (pertaining to me) and any resulting reports. To perform a one-time authorization to transact business (pertaining to me) with the VT Department of Motor Vehicles.

TA-VG-116 (d) INTERNET 8/07 JTB

Information requested (be specific, if necessary use separate sheet of paper):

The information requested may be disclosed if its use is authorized under the Driver Privacy Protection Act. The information being requested is:

You must initial the appropriate line(s)/category(ies) below:

1.For use by any government agency, including any court or law enforcement agency, in carrying out its functions, or any private person acting on behalf of a government agency in carrying out its functions. Appropriate documents identifying requester are required*.

2.For use in connection with matters of motor vehicles 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. An explanation that details the reason(s) why you feel you qualify under this category must be attached to this document.

3.For use in the formal course of business by a legitimate business or its agents, employees, or contractors:

a.To verify the accuracy of personal information submitted by the individual to the business or its agents, employees, or contractors; and

b.If the 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 requester are required*.

4.For use in connection with any proceeding in any court or government 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 any court. An explanation that details the reason(s) why you feel you qualify under this category must be attached to this document.

5.For use in research activities, and for use in producing statistical reports, so long as the personal information is not published, re- disclosed, or used to contact individuals. An explanation that details the reason(s) why you feel you qualify under this category must be attached to this document.

6.For use by any insurer or insurance support organization, or by a self-insured entity, or its agents, employees, or contractors, in connection with claims investigation activities, antifraud activities, rating, or underwriting. Appropriate documents identifying requester are required*.

7.For use in providing notice to the owner or lien-holder of a towed or impounded vehicle.

8.For use by any licensed private investigative agency or licensed security service for any purpose permitted under this section. Appropriate documents identifying requester are required*.

9.For use by an employer, of its agent or insurer, to obtain or verify information relating to a holder of a commercial driver's license which is required under the Commercial Motor Vehicle Safety Act of 1996 [Title XII of Public Law 99-570].

10.For use in connection with the operation of private toll transportation facilities.

11.For any use specifically authorized by law that is related to the operation of a motor vehicle or public safety. An explanation that details the reason(s) why you feel you qualify under this category must be attached to this document.

12.Unrestricted or specified use with written consent of the person who is the subject of the information. ("Release portion" on other side of this form must be completed in full.)

In requesting and using this information I acknowledge that this disclosure and any re-disclosure is subject to the Driver Privacy Protection Act (18 U.S.C. §2723). This is signed and the request made subject to the penalties of 18 U.S.C. §2723 and 23 V.S.A §202.

Driver License/Corporate Number of Requester:

Upon receipt of this request by the Vermont Department of Motor Vehicles, it will be reviewed by the appropriate department personnel to determine whether this request conforms to (DPPA) protocol and requirements. Failure to meet these qualifications will result in a denial of your request.

*Appropriate documents identifying requester are required – You must include copies of your identification and documents verifying you are authorized to obtain this information. Failure to meet these qualifications will result in a denial of your request. If you are unsure what documents are required, call 802.828.2000

FOR DEPARTMENT USE ONLY – DO NOT WRITE ANYTHING BEYOND THIS POINT

This request is hereby denied as the record(s) is/are exempt from inspection and copying for the following reason:

They are records which, by law, are designated confidential or by a similar term.

They are records which, by law, may only be disclosed to specifically designated persons.

You have the right to appeal this denial to the Commissioner of Motor Vehicles (appeal must be in writing).

Director, Vermont Department of Motor Vehicles: