HSMV Form 94010: Sworn Statement for Obtaining Crash Report

Under Requester's information, enter the Name of Requester, Date of Request and Reference # (Case/File Name).

Enter the Street Address, Telephone Number and Fax Number, then the City, State, Zip and Email Address.

Under Crash information, enter the Date of Crash, the Crash Report # (if known) and the Law Enforcement Agency Case # (FHP or other, if known).

Enter the Location of Crash and the County (where crash occurred).

Enter the Parties Involved.

Within 60 days of filing, a crash report may be made available only to the following persons (Pursuant to § 316.066(2)(b), Fla. Stat.); select the option that best describes you (select one).

Persons eligible to obtain a crash report during this 60-days period remain eligible once the 60 days has expired.

Mark I am a party involved in the crash.

Mark I am the legal representative of and enter the party involved in the crash, then the State / Bar number.

Mark I am a licensed insurance agent of, an insurer of, or an insurer to which coverage has been applied for, and enter the party involved in the crash and the License number.

Mark I am a person under contract to provide claim or underwriting information for a qualifying insurer, and enter the Name of insurer.

Mark I represent a victim services program, and enter the Name of program.

Mark I represent a federal, state, or local governmental agency or am a private person or entity acting on behalf of such agency in carrying out its functions, and enter the Agency name.

Mark I represent a radio or television station licensed by the FCC or newspaper qualified to publish legal notices under §§ 50.011 & 50.031, Fla. Stat. (Specified personal information must be redacted.), and enter the Name of media organization.

Mark I am a third party acting on behalf of a person or entity listed in the other selections for disclosure of the crash report only to such person or entity, designate such person or entity by circling and completing that selection, and enter the Name of person or entity.

Sworn to (or affirmed) and subscribed before the notary by means of physical presence or online notarization, by the Name of Requester.

The notary section has personally known or produced identification and the Type of identification produced.

The notary section has STATE OF, COUNTY OF, (NOTARY SEAL), Signature of Notary, the commissioned name of the notary public (Print, Type or Stamp) and My Commission expires.

Under penalty of perjury, you swear (or affirm) that the answers are true and complete and that the requested report will not be used for commercial solicitation of crash victims or knowingly disclosed to any third party for purposes of such solicitation.

Pursuant to § 316.066(2)(f), Fla. Stat., crash reports may be made available 60 days after filing to any person or entity.

In accordance with any of the permissible uses listed in the federal Driver's Privacy Protection Act (DPPA), 18 U.S.C. § 2721(b).

Pursuant to the DPPA's resale and redisclosure requirements in 18 U.S.C. § 2721(c).

Select all permissible uses listed in 18 U.S.C. § 2721(b) for which you are eligible.

Mark for use by any government agency, including any court or law enforcement agency, in carrying out its functions, or any private person or entity acting on behalf of a Federal, State, or local agency in carrying out its functions.

Mark for use in connection with matters of 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 survey research; and removal of non-owner records from the original owner records of motor vehicle manufacturers.

Mark for use in the normal course of business by a legitimate business or its agents, employees, or contractors, but only to verify the accuracy of personal information submitted by the individual to the business or its agents, employees, or contractors.

Mark for use in the normal course of business by a legitimate business or its agents, employees, or contractors, but only 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.

Mark for use in connection with any civil, criminal, administrative, or arbitral proceeding in any Federal, State, or local court or 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 a Federal, State, or local court.

Mark for use in research activities, and for use in producing statistical reports, so long as the personal information is not published, redisclosed, or used to contact individuals.

Mark 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.

Mark for use in providing notice to the owners of towed or impounded vehicles.

Mark for use by any licensed private investigative agency or licensed security service for any purpose permitted under this subsection.

Mark for use by an employer or its agent or insurer to obtain or verify information relating to a holder of a commercial driver's license that is required under 49 U.S.C. chapter 313.

Mark for use in connection with the operation of private toll transportation facilities.

Mark for use by any requester, if the requester demonstrates it has obtained the written consent of the individual to whom the information pertains.

Mark for any other permissible use authorized in 18 U.S.C. § 2721(b), and provide documentation describing such use with specific citation to the respective provision of the federal act authorizing such use.

Sign on the Signature of Requester line. Under penalty of perjury, you certify that you are entitled to receive the requested report according to the selected DPPA permissible use(s), that you understand you must comply with DPPA's resale and redisclosure requirements, and that the requested report will not be used for commercial solicitation of crash victims or knowingly disclosed to any third party for purposes of such solicitation.

Section 316.066(3), Fla. Stat., provides criminal penalties against persons who knowingly obtain confidential crash reports they are not entitled to or who use such confidential information in violation of a filed written sworn statement. The statute also authorizes civil penalties against persons who knowingly disclose or use such confidential information for purposes not permitted under DPPA.