REQUEST FOR VEHICLE INFORMATION

$14.00 Fee required for each record requested or $44.00 Fee for each certified record The most current version of this form can be found at www.dmv.pa.gov (see reverse side for instructions and fee information)

A REQUESTER INFORMATION B END USER OF INFORMATION BEING REQUESTED

NAME NAME OF BUSINESS

ADDRESS: P.O. Box number may be used in addition to the actual address, but cannot be used as the only address. ADDRESS: (P.O. Box not accepted), need to provide physical location of business/residence

CITY STATE ZIP CODE CITY STATE ZIP CODE

DAYTIME TELEPHONE NUMBER (Required) REFERENCE NUMBER CONTACT PERSON PHONE #

NAIC NUMBER POLICY NUMBER

SIGNATURE X CLAIM NUMBER

NOTARIZATION NOT REQUIRED WHEN REQUESTING YOUR OWN RECORD D MICROFILM Certified - ☐ YES ($44.00 Required)

C VEHICLE INFORMATION (read instructions for number 2 on the back of the form) CHECK (✓) ONE ONLY: SEE REVERSE SIDE FOR EXPLANATION OF INFORMATION YOU WILL RECEIVE. ☐ TITLE - CURRENT RECORD ☐ ODOMETER - CURRENT RECORD ☐ TITLE - PREVIOUS RECORD ☐ ODOMETER - PREVIOUS RECORD ☐ ENCUMBRANCE ☐ INSURANCE ☐ OTHER ________________

TAG NUMBER TITLE NUMBER

VEHICLE IDENTIFICATION NUMBER DATE OF ACCIDENT (if applicable) E VEHICLE OWNER RELEASE

NAME I ________________ HEREBY REQUEST THE PA Department of Transportation to furnish a copy of my PA vehicle record to, _____ NAME OF REQUESTER

ADDRESS

CITY STATE ZIP CODE SIGNATURE OF VEHICLE OWNER DATE

F AFFIDAVIT OF INTENDED USE - YOU MUST CHECK (✓) ONE ITEM

_____ 1. 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 or political subdivision in carrying out its functions. _____ 2. 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. _____ 3. 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; 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. _____ 4. 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. _____ 5. 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. _____ 6. For use by an 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. _____ 7. For use in providing notice to the owners of towed or impounded vehicles. _____ 8. For use in connection with the operation of private toll transportation facilities. I hereby certify that ________________ will use the vehicle information requested pursuant to Section 6114 of the Pennsylvania Vehicle Code, for the purpose checked above only and for no other reason. This affidavit is filed in compliance with Section 607 of the Fair Credit Reporting Act and the Federal Drivers Privacy Protection Act. I/We state that I/we have read and signed this form after its completion, and I/we swear or affirm that the statements made herein are true and correct, and that any statement made on or pursuant to this form is subject to the penalties of 18 Pa.C.S. Section 4904(b) (relating to unsworn falsifications), which shall include punishment of a fine not exceeding $2,500, or to a term of imprisonment of not more than one year, or both. SIGNATURE OF REQUESTER TITLE OF REQUESTER (if applicable) __________________

NOTARIZATION SUBSCRIBED AND SWORN TO BEFORE ME: MONTH DAY YEAR

SIGNATURE OF PERSON ADMINISTERING OATH

SEAL SIGN IN PRESENCE OF NOTARY

MESSENGER NO.