Mv 15F Form – Fill Out and Use This PDF

List of Permissible Uses - Driver Privacy ProtectionAct

èStep 1)Check the permissible use(s) for the records that you want:

TheFederalDriver’sPrivacyProtectionAct(18U.S.C.§2721.etseq.)(“DPPA”)regulatesaccesstoMotorVehiclesrecords.Recipientherebycertifiesthatthe informationprovidedhereunderbyDMVshallbeusedsolelyforthefollowingpurpose(s).

(Recipient must check all that apply.)

1.Useinanycivil,criminal,administrative,orarbitralproceedinginanycourtoragency,includingtheserviceofprocess,investigationin anticipationoflitigation,andtheexecutionorenforcementofjudgmentsandordersorpursuanttoacourtorder.(18U.S.C.§2721(b)(4))

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

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

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

5.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))

6.Use required under NYSVehicle andTraffic Law,Article 19A- Special Requirements for Bus Drivers. (18 U.S.C. §2721 (b)(14))

7.Use required under NYSVehicle andTraffic Law,Article 19B - Special Requirements for Commercial Motor Carriers.

(18 U.S.C. §2721 (b)(14))

8.Use by any government agency, including any court or law enforcement agency, in carrying out its functions. (18 U.S.C. §2721 (b)(1))

9.Use by any private person or entity acting on behalf of a federal, state, or local agency in carrying out its functions. (18 U.S.C. §2721 (b)(1))

10.Use in matters of motor vehicle or driver safety. (18 U.S.C. §2721 (b)(2))

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

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

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

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

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

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

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

18.For 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-15GC). (18 U.S.C. §2721 (b)(13))

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:

(18 U.S.C. §2721 (b)(14))

20.Use in research activities and in producing statistical reports, as long as the personal information is not published, disclosed or used to contact individuals. (18 U.S.C. §2721 (b)(5))

Toknowinglymakeafalsestatementorconcealamaterialfactinthiswrittenstatementmaybepunishableasacriminaloffense.Inaddition,anyonewhomakes falserepresentationtoobtainanypersonalinformationfromanindividual’sMotorVehiclesrecordissubjecttofederalcriminalfinesundertheDriver’sPrivacy ProtectionAct(DPPA).

èStep 2)Attach a copy of your driver license or government-issued identification card. (Youmaycoverthepicture.)

èStep 3)Sign the following Privacy Certification:

I certify that I have read the Driver’s Privacy ProtectionAct (18 U.S.C. §2721 et seq.) and will comply fully with the terms of such law. I also certify that I shall notrequestoruseanyinformationprovidedbytheDepartmentofMotorVehiclesthatisnotspecificallyauthorizedbytheDriver’sPrivacyProtectionAct.

I certify that if I receive or have access to records or information from the DMV, I shall not (i) use such records or information for civil immigration purposes or

(ii)disclose such records or information to any agency that primarily enforces immigration law, such as U.S. immigration and customs enforcement and U.S. customsandborderprotection,ortoanyemployeeoragentofanysuchagencyunlesssuchdisclosureispursuanttoacooperativearrangementbetweencity,state andfederalagencieswhichdoesnotenforceimmigrationlawandwhichdisclosureislimitedtothespecificrecordsorinformationbeingsoughtpursuanttosuch arrangement.Icertifythat,inadditiontotherequirementsof18USC2721(c),Ishallkeepforaperiodoffiveyearsrecordsofallusesandidentifyingeachperson orentitythatprimarilyenforcesimmigrationlawthatreceiveddepartmentrecordsorinformationfromsuchcertifyingpersonorentity.Ishallmaintaintherecords inamannerandformprescribedbythecommissioner,andIshallmakethemavailableforinspectionuponthecommissioner’srequest.

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Requester’s Signature (required)Date

Requester - PrintNameHere

MailyourrequesttoNEWYORKSTATEDEPARTMENTOFMOTORVEHICLES,FREEDOMOFINFORMATIONLAWOFFICE,6 EMPIRE STATE PLAZA, ROOM 136B,ALBANYNY12228. Or send it via email to dmv.sm.foil@dmv.ny.gov.

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