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Motor Vehicle Record Request - Arizona

Motor Vehicle Record Request Form. This is a Arizona form and can be used in Motor Vehicle Division Statewide .
 Fillable pdf Last Modified 9/28/2012
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46-4416 R01/15 azdot.gov Mail Drop 504M Records Unit Motor Vehicle Division PO Box 2100 Phoenix AZ 85001-2100 MOTOR VEHICLE RECORD REQUEST · Must be signed and notarized on the back · At least one permissible use must be checked on the back, unless you are requesting your own record · See required fees below Motor Vehicle Division offers a single electronic portal for authorized government agencies and commercial companies to access motor vehicle records online from Electronic Data Services (eds@azdot.gov) The manner in which the Motor Vehicle Division (MVD) may release information from its driver license or motor vehicle records is regulated by the Federal Driver's Privacy Protection Act (or DPPA), 18 U.S.C. 2721-2725 and Title 28, Chapter 2, Article 5 of the Arizona Revised Statutes and 49 CFR 384.225. It is the responsibility of the individual or entity making a request to gain knowledge of all federal and state laws which govern access to and use of MVD records, and to determine eligibility under these laws. Anyone who knowingly obtains, discloses, or uses personal information from an MVD record for a use not permitted under these statutes, and anyone requesting the disclosure of personal information who misrepresents their identity or makes a false statement in connection thereto with the intent to obtain such information in a manner not authorized by law, is subject to civil and/or criminal penalties. Requester Information -- proof of identification required Requester Name (first, middle, last, suffix) Mailing Address Representing (name of business or other organization) Driver Record Type Uncertified 39-Month Other Records Vehicle Record Type Uncertified Certified CDL (Commercial Driver License) Record (no photo available) Must check CDL Use on back Driver License Number or Other ID City Daytime Phone Number ( State ) Zip Certified 5-year Driver History - extended Uncertified Lienholder TSS Assignment Notice Vehicle History Certified Driver Packet (government use only) Violation Date: ____________ Time Frame:_______________ Criteria ­ At a minimum, one Primary Criteria is required (unless Permissible Use #11 is checked). If the criteria you provide below results in no record or multiple records, then additional criteria will be needed to locate the specific record requested. Providing additional criteria with your initial request may avoid delays in processing, or having to pay for "no record found". Arizona Driver License/Customer # Driver Record ­ Primary Criteria Licensee Full Name (first, middle name or initial, last, suffix) Has not applied for license License is suspended or revoked Driver Record ­ Secondary Criteria Licensee Date of Birth (month/day/year) Licensee Residence Address License Expiration Date (month/day/year) City State Zip Vehicle Record ­ Primary Criteria Vehicle Identification Number Owner Full Name (first, middle, last, suffix) Arizona License Plate Number No plate has been issued Vehicle Record ­ Secondary Criteria Owner Residence Address City State Zip Fees (per record or document) No fee required for government agencies Lienholder Record ............................................ $1.50 Over-the-Counter (while you wait) .........$3.00 Mail-in (must be notarized) ....................$3.00 Drop-off ..................................................$2.00 Supporting microfilm documents ...........$3.00 VIN Search for each month searched... $2.00 Customer Number Date Paid Uncertified Certified $5.00 $5.00 $5.00 $5.00 $5.00 MVD Use Comments Record Located Amount Paid Check Number MVD Agent Yes No American LegalNet, Inc. www.FormsWorkFlow.com I am requesting my own record (If this box is checked, a Permissible Uses box does not need to be checked below). Permissible Uses ­ I understand that the DPPA, as adopted in Arizona law, requires me to have a permissible use for requesting and receiving an MVD record that contains personal identifying information (e.g., a person's driver license photograph/image, driver license number, name, address and medical/disability information). Based on the specific uses checked below, I hereby certify that I am entitled to obtain the requested record under the authority of ARS Title 28, Chapter 2, Article 5. 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 government agency in carrying out its functions (Permissible Use #1) For use by an attorney licensed to practice law or by a licensed private investigator in connection with any civil, criminal, administrative or arbitration 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 a court order Professional License Number Court Name and Case Number (if available) (Permissible Use #4) insurance support organization or by a self-insured entity or its agents, employees or contractors in connection with claims investigation activities and antifraud activities, rating or underwriting (Permissible Use #6) For use by an employer or its agent or insurer to obtain or verify information relating to a holder of a commercial driver license that is required under the commercial motor vehicle safety act of 1986 (49 U.S.C. 31301 through 31317) (Permissible Use #9) For any other use in response to requests for individual motor vehicle records if the state has obtained the express consent of the person to whom the personal information pertains (two Primary Criteria and one Secondary required) (Permissible Use #11) For use by any requester if the requester demonstrates he or she has obtained the written consent of the individual to whom the information pertains (signed and notarized Consent to Release Motor Vehicle Record­One-Time, form # 96-0463, must be attached) (Permissible Use #13) Only if a box is checked for one or more of the six permissible uses above, may the requester specifically request the person's driver license photograph/image or medical/disability information. Photo/Image (select locations only) For use by any insurer that writes automobile liability or motor vehicle liability policies and that is under the jurisdiction of the department of insurance or Uncertified Certified CDL Use ­ uncertified (only the following users or their authorized agents may receive the designated info
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