Form 303RM 0097 "Records Request & Consent to Release" - Oklahoma

What Is Form 303RM 0097?

This is a legal form that was released by the Oklahoma Department of Public Safety - a government authority operating within Oklahoma. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2017;
  • The latest edition provided by the Oklahoma Department of Public Safety;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 303RM 0097 by clicking the link below or browse more documents and templates provided by the Oklahoma Department of Public Safety.

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Download Form 303RM 0097 "Records Request & Consent to Release" - Oklahoma

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Department of Public Safety
Records Management Division
RECORDS REQUEST &
CONSENT TO RELEASE
Form Instructions
Please fill out completely all applicable portions of the Records Request and Consent to Release form.
Mail the form and all applicable fees, using one of the forms of payment listed at the bottom of the
form, to:
Department of Public Safety
Records Management Division
P. O. Box 11415
Oklahoma City, OK 73136-0415
Please include a self-addressed appropriately stamped envelope with your request. The Department will
not mail documents C.O.D. Please do not use Federal Express (FedEx) or United Parcel Service (UPS).
You may also present the completed form and fees at the Department of Public Safety, 3600 North
Martin Luther King Avenue (southeast corner of Northeast 36th and Martin Luther King Avenue),
Oklahoma City.
To obtain a regular driving record summary (Motor Vehicle Report, or MVR), you may present the
completed form and the $25 fee at any motor license agency in the state.
The Department of Public Safety does not issue National Driving Records.
The Department of Public Safety is not affiliated with DocViews.
To preserve your rights and privacy under the Driver’s Privacy Protection Act, 18 U.S.C.,
Sections 2721 through 2725:
Requests for records can not be made by telephone or e-mail
Records can not be faxed or e-mailed
DPS 303RM 0097 09/2017
Department of Public Safety
Records Management Division
RECORDS REQUEST &
CONSENT TO RELEASE
Form Instructions
Please fill out completely all applicable portions of the Records Request and Consent to Release form.
Mail the form and all applicable fees, using one of the forms of payment listed at the bottom of the
form, to:
Department of Public Safety
Records Management Division
P. O. Box 11415
Oklahoma City, OK 73136-0415
Please include a self-addressed appropriately stamped envelope with your request. The Department will
not mail documents C.O.D. Please do not use Federal Express (FedEx) or United Parcel Service (UPS).
You may also present the completed form and fees at the Department of Public Safety, 3600 North
Martin Luther King Avenue (southeast corner of Northeast 36th and Martin Luther King Avenue),
Oklahoma City.
To obtain a regular driving record summary (Motor Vehicle Report, or MVR), you may present the
completed form and the $25 fee at any motor license agency in the state.
The Department of Public Safety does not issue National Driving Records.
The Department of Public Safety is not affiliated with DocViews.
To preserve your rights and privacy under the Driver’s Privacy Protection Act, 18 U.S.C.,
Sections 2721 through 2725:
Requests for records can not be made by telephone or e-mail
Records can not be faxed or e-mailed
DPS 303RM 0097 09/2017
RECORDS REQUEST & CONSENT TO RELEASE
Department of Public Safety
Per Record Fee
I hereby request the following driver record(s):
Regular
Certified
Oklahoma driving record summary (Motor Vehicle Report, or MVR) [state law limits this summary to three years] ...............$25.00 or ..........$28.00
Collision Report. Provide Date: ___________________ City/County ________________________________ ................ $7.00 or .......... $10.00
Per
Per Certified
Other Driving Record(s) (please specify record by type and date): _____________________________________
Page Fee
Record Fee
____________________________________________________________________________________________ ............... $ 0.25 or ........... $ 3.00
[For vehicle records, contact Oklahoma Tax Commission. For birth certificates, contact Department of Health]
Total fee due is cost per line
for:
Driver’s Name: _______________________________________________________________________________ Sex: _____________________
Driver License Number: ________________________________________________________________ Date of Birth: _____________________
mm/dd/yyyy
Check the following applicable statement:
I am the person named in the record(s) sought.
I am requesting the record(s) of another person.
If you are not the person named in the record(s) sought, provide the reason(s) you are entitled to this record without approval of the named
person [please check all that apply]. If none of these reasons apply, you must have the named person sign the Consent to Release below.:
1.
Government Agency (federal, state, or local, including court or law enforcement): for carrying out its functions †
2.
Legal: in connection with any court, administrative, arbitral, or self-regulatory body; service of process; investigation in anticipation of litigation;
execution or enforcement of judgment or order of a court.
3.
Research Activities or Statistical Reports: personal information shall not be published, re-disclosed, or used to contact individuals †
4.
Insurance Company, Insurance Support Organization, Self-insured Entity: for claims investigation, anti-fraud, rating or underwriting activities †
5.
Licensed Private Investigative Agency or Licensed Security Service: for any purpose permitted under 18 U.S.C. §2721, subsection (b) †
6.
Employer of Commercial Driver License Holder: to obtain or verify information required under 49 U.S.C., Chapter 313 †
7.
Other: for use specifically authorized under the laws of the State of Oklahoma related to the public safety
Statutory citation: ___________________________________________________________________
CONSENT TO RELEASE by Person Named in Request [if none of the reasons above apply, consent to release is required. Employers MUST
have consent to release a driving record when it is to be used for purposes other than 49 U.S.C., Chapter 313.]
________________________________________________________
___________________________________________________
Printed Name of Person Named in Request
Signature of Person Named in Request
By signing above, I voluntarily give consent to the Department of Public Safety or any Motor License Agency to release the above-named record(s) to the person
making this Records Request. I understand, as required by the federal Driver Privacy Protection Act (DPPA), 18 U.S.C. Section 2721, et seq., the Department
of Public Safety or any Motor License Agency will not release personal information from my driving record unless I consent by waiving my right to privacy
under the DPPA, or unless the Department is required or authorized by DPPA to release personal information without my consent as enumerated above.
AFFIRMATION of Person Making Request
Pursuant to 12 O.S. §426, I state under the penalty of perjury that the requested information is being solicited solely for the reason(s) checked above or at the
consent of the named person. I understand the personal information furnished is confidential under Federal and State laws and is being released to me only for
the reason I have indicated above or at the consent of the named person, and that it is unlawful for me to furnish the information to any unauthorized person
or entity or to be used for any unauthorized purpose and if I release any of such information to another authorized person, I understand that I must inform
that person of his duties and responsibilities under the Drivers Privacy Protection Act [21 U.S.C. §§ 2421, et seq.] and his obligations to use such information
only of the purposes set out therein and his civil and criminal liabilities if he violates these duties, and his obligation to inform subsequent authorized recipients
of said information of their identical obligations and duties. I further agree to indemnify and held harmless both the Oklahoma Department of Public Safety
and OK.gov from any and all liability and penalties associated with my or my successor’ or assignees’ wrongful use and/or release of such information.
________________________________________________________
___________________________________________________
Printed Name of Person Making Request
Signature of Person Making Request
________________________________________________________
___________________________________________________
mm/dd/yyyy
† Print Agency/Company Name(if item 1, 3, 4, 5 or 6 was checked above)
Date
_______________________________________________________________________________________________________________________
Address
City
State
Zip
Mail completed form along with appropriate fees to:
Fees are listed above.
Department of Public Safety
Please send total amount due in form of :
Records Management Division
Cashier’s Check, Money Order, Personal or Business Check
P. O. Box 11415
Cash is accepted only when paying in person.
Oklahoma City, OK 73136-0415
Record fees are in accordance with Oklahoma Statutes.
DPS 303RM 0097 09/2017
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