Form PS2502A "Dvs Record Request" - Minnesota

What Is Form PS2502A?

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

Form Details:

  • Released on October 1, 2019;
  • The latest edition provided by the Minnesota 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 fillable version of Form PS2502A by clicking the link below or browse more documents and templates provided by the Minnesota Department of Public Safety.

ADVERTISEMENT
ADVERTISEMENT

Download Form PS2502A "Dvs Record Request" - Minnesota

314 times
Rate (4.7 / 5) 16 votes
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
Print Form
DRIVER AND VEHICLE SERVICES
Mail requests to:
445 Minnesota Street,Saint Paul, MN 55101-5161
Driver and Vehicle Services
Phone: (651) 296-2940 TTY: (651) 282-6555
Records Unit
dvs.dps.mn.gov
445 Minnesota St., Suite 161
DV S R ECORD RE QUEST
St. Paul, MN 55101-5161
Payment must accompany request - Please make check or money order out to: Driver & Vehicle Services.
o Payments must be made in U.S. dollar amounts.
o Please DO NOT send cash.
o If mailing in: Requester is required to include a legible copy of driver license, government issued
identification card, or notarized signature.
o For a driving record, complete Section A.
o For a motor vehicle record, complete Section B.
o All requestors must complete Section C
o If you are not the subject of the record being requested you must complete Section D by initialling the appropriate
permissible use.
Please Check One Box:
I am requesting a copy of my own record. - Proceed to fill out section A or B and section C.
I am requesting a copy of the record of another person, and I have attached their written consent.
Other - for all other record requests, you must initial at least one permissible use in Section D and complete the additional
required information.
A. Driving Record Request:
Minnesota DL/ID Number:
Driver's Name: Last, First, Middle
Date of Birth:
-
-
-
-
Check all that apply. For multiple records, please attach a multiple record supplement to this request form.
Non-Certified Copy (5-year History - Convictions only)
Requester
Requester is
Payment made out to
IS subject
NOT subject
Driver & Vehicle
Certified Copy
Services
of data
of data
Non-Certified Copy
$9.00
$9.50
Certified Copy + Letter to show the date the driver's license was
(5 year history)
originally issued
Certified Copy
$10.00
$10.50
Specific details about driving record request:
Certified Copy +
License Issuance
$10.00
$10.50
Date Letter
B. Motor Vehicle Record Request
Vehicle Year & Make:
Minn. License Plate #:
Vehicle Identification Number:
Motor Vehicle Record
Requester
Requester is
Payment made out to
IS subject
NOT subject
Driver & Vehicle
Certified Motor Vehicle Record
Services
of data
of data
Non-Certified Copy
$9.00
$9.50
Title History
Certified Copy
$10.00
$10.50
Specific details about motor vehicle request:
ge, in
$1.00 per printed pa
Vehicle Title History
addition to the record
fee.
Page 1 of 4
PS2502A-23 (10/2019)
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
Print Form
DRIVER AND VEHICLE SERVICES
Mail requests to:
445 Minnesota Street,Saint Paul, MN 55101-5161
Driver and Vehicle Services
Phone: (651) 296-2940 TTY: (651) 282-6555
Records Unit
dvs.dps.mn.gov
445 Minnesota St., Suite 161
DV S R ECORD RE QUEST
St. Paul, MN 55101-5161
Payment must accompany request - Please make check or money order out to: Driver & Vehicle Services.
o Payments must be made in U.S. dollar amounts.
o Please DO NOT send cash.
o If mailing in: Requester is required to include a legible copy of driver license, government issued
identification card, or notarized signature.
o For a driving record, complete Section A.
o For a motor vehicle record, complete Section B.
o All requestors must complete Section C
o If you are not the subject of the record being requested you must complete Section D by initialling the appropriate
permissible use.
Please Check One Box:
I am requesting a copy of my own record. - Proceed to fill out section A or B and section C.
I am requesting a copy of the record of another person, and I have attached their written consent.
Other - for all other record requests, you must initial at least one permissible use in Section D and complete the additional
required information.
A. Driving Record Request:
Minnesota DL/ID Number:
Driver's Name: Last, First, Middle
Date of Birth:
-
-
-
-
Check all that apply. For multiple records, please attach a multiple record supplement to this request form.
Non-Certified Copy (5-year History - Convictions only)
Requester
Requester is
Payment made out to
IS subject
NOT subject
Driver & Vehicle
Certified Copy
Services
of data
of data
Non-Certified Copy
$9.00
$9.50
Certified Copy + Letter to show the date the driver's license was
(5 year history)
originally issued
Certified Copy
$10.00
$10.50
Specific details about driving record request:
Certified Copy +
License Issuance
$10.00
$10.50
Date Letter
B. Motor Vehicle Record Request
Vehicle Year & Make:
Minn. License Plate #:
Vehicle Identification Number:
Motor Vehicle Record
Requester
Requester is
Payment made out to
IS subject
NOT subject
Driver & Vehicle
Certified Motor Vehicle Record
Services
of data
of data
Non-Certified Copy
$9.00
$9.50
Title History
Certified Copy
$10.00
$10.50
Specific details about motor vehicle request:
ge, in
$1.00 per printed pa
Vehicle Title History
addition to the record
fee.
Page 1 of 4
PS2502A-23 (10/2019)
DVS Records Request
C. Certification
Remember to attach a photocopy of the requester's driver license, government-issued identification card, or signature must be
notarized if submitting by mail.
The Driver Privacy Protection Act (DPPA) is enforced by the U.S. Department of Justice, which may seek civil and criminal penalties for improperly
obtaining, disclosing or using personal information from a motor vehicle record for a purpose not permitted by the DPPA. In addition, private citizens
may also seek civil damages in Federal Court.
Certification I (we) certify that the information and statements on this request are true and correct, comply with the provisions of the Federal Driver's
Privacy Protection Act and understand that the willful, unauthorized disclosure of information obtained from these records for a purpose other than
stated on this request, or the sale or other distribution of the information to a person or organization not disclosed in this request may result in penalties
imposed under Title 18 U.S.C. Section 2724.
Date:
Signature of Requester/Representative: X
Printed Name of Requester:
Printed Name of Business:
Email Address:
Daytime Phone:
Record will not be emailed. This is for contact purposes only.
Mailing Address to Send Record:
Name or Business Name:
Street Address:
City:
State:
Zip:
Notary Information
(If applicable)
Subscribed and sworn before me this ______, day of __________________________, _________.
My Commission expires
/
/
Notary Public Signature
(Seal)
Requester's
Date:
Signature
Access to Driver’s License and Motor Vehicle records is governed by:
• Minnesota Statutes, chapters 168.346; 171.12 subd. 7; and 171.12 subd. 7a • United States code title 18, sections 2721-2725 and
Minn. Statute, Chapter 13 • Personal information is classified as private data.
The Department in accordance with Minnesota Statutes, chapter 138.17, will retain this record request.
If you require the return of your request with the record, send the original
request and a duplicate. The copy will be returned.
DVS USE ONLY
Proof of Requester's Identification
Remarks/Paid Stamp
Fee Charged
Driver's License or ID Number _________________________
$
Other Photo Identification _________________________
PS2502A-23 (10/2019)
Page 2 of 4
DVS Records Request
D. Requester's Information - Please select one:
Authorization:
PERMISSIBLE USES OF MOTOR VEHICLE DATA AS PROVIDED IN UNITED STATES CODE, TITLE 18, SECTION 2721
You must tell us why you want the records you are requesting. Sign your initials next to each use under which you claim
access. Driver and Vehicle Services reserves the right to request such additional information as may be necessary to determine
whether you qualify for access.
The requestor is an employee of a federal, state, or local government agency, or a private person acting on behalf of a federal,
state, or local government agency, and the records will be used to carry out the official functions of such federal, state, or local
1.
government agency. (Please attach proof of Requestor's authority to act on behalf of a government agency.)
Name of agency:
Name of agency's contact:
Telephone number of contact:
Email address of contact:
The records will be used 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
2.
vehicle market research activities, including survey research, and removal of non-owner records from the original owner records of
motor vehicle manufacturers. (A written explanation detailing the reasons you contend that you qualify for access under this category
must be attached to this Agreement.)
The records will be used in the normal course of business by a legitimate business or its agents, employees, or contractors but only
(i) to verify the accuracy of personal information submitted by the individual to the business or its agents, employees, or contractors,
3.
and (ii) if such information as so submitted is not correct or is no longer correct, to obtain the correct information, but only for the
purpose of preventing fraud by, pursuing legal remedies against, or recovering on a debt or security interest against, the individual. If acting
as agent of lienholder, must submit proof of contract with lienholder.
Name of business:
Name of business's contact:
Business tax ID number:
Telephone number of contact:
Email address of contact:
The records will be used in connection with a civil, criminal, administrative, or arbitral proceeding in federal, state, or local court or
4.
agency or before a 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.
Requestor is (check one):
attorney
represented litigant
pro se litigant
other (attach explanation)
Name of court, agency, or self-regulatory body:
Name of involved parties:
Name of court:
Name of case or matter:
Expected forum:
Name of case or matter:
Case/matter number:
Date of occurrence:
Case number:
The requester is an attorney and the records will be used to title a manufactured home in accordance with the process defined in
Minnesota Statute § 168A.143.
The records will be used in research activities and for use in producing statistical reports, but the personal information in the records
5.
will not be published, re-disclosed, or used to contact the individual. (A written explanation detailing the reasons you contend that
you qualify for access under this category must be attached to this Agreement.)
The requestor is an agent, employee, or contractor of an insurer or insurance support organization, and the record will be used in
connection with claims investigation activities, anti-fraud activities, rating, or underwriting. (Please attach proof of the Requestor's
6.
status.)
Name of insurer or insurance support organization:
Name of insurer or support organization's contact:
Email address of contact:
Telephone number of contact:
The records will be used to provide notice to owners (including lienholders) of towed or impounded vehicles.
7.
Name of towing company:
Minnesota License Number:
Name of company's contact:
Telephone number of contact:
Email address of contact:
PS2502A-23 (10/2019)
Page 3 of 4
DVS Records Request
Authorization:
PERMISSIBLE USES OF MOTOR VEHICLE DATA AS PROVIDED IN UNITED STATES CODE, TITLE 18, SECTION 2721
You must tell us why you want the records you are requesting. Sign your initials next to each use under which you claim
access. Driver and Vehicle Services reserves the right to request such additional information as may be necessary to determine
whether you qualify for access.
The requestor is a licensed private investigative agency or licensed security service, and the Requestor will use the record for a
8.
permitted purpose. (Photocopy of Minnesota Private Investigator's License must be attached. Also, if you claim access under this paragraph,
you must initial another paragraph indicating the permitted use, and you must provide any applicable attachments required therein.)
Name of private investigative agency or licensed security service:
Minnesota license number:
Name of agency or service's contact:
Telephone number of contact:
Email address of contact:
The requestor is an employer or its agent or insurer and the records will be used 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. (Please attach proof of the Requestor's status.)
9.
Name of employer:
Name of employer's contact:
Telephone number of contact:
Email address of contact:
The records will be used in connection with the operation of a private toll transportation facility.
10.
Name of private toll transportation facility:
Licensing entity and number:
Telephone number of contact:
Name of facility's contact:
Email address of contact:
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
11.
whom such personal information pertains.
For bulk distribution surveys, marketing, or solicitation if the state has obtained express consent of the person whom such personal
12.
information pertains.
For any other use specifically authorized under the law of the state that holds the record, if such use is related to the operation of a motor
13.
vehicle or public safety.
List specific statutory authorization:
Any additional specifics tied to this request or permissible use to obtain the requested information:
PS2502A-23 (10/2019)
Page 4 of 4
Page of 4