Name: ____________________________________ Account# : __________________________
Organization (if applicable): ______________________Title: ______________________________
Address: ___________________________________State: _____________________________
City: _______________________________________Zip: _______________________________
Phone: _____________________________________e-mail address: ______________________
Verification of your eligibility to receive the requested records.Please review the exceptions listed on the bottom of this form and fill in the code that corresponds with your request.
If you selected code "J", complete this section
If you selected code "M", complete this section
It is unlawful for personal information to be used for any purpose not permitted under these exceptions. Furthermore, it is unlawful for any person to make false representation in order to obtain personal information from DMV records.
The owner of personal information may bring civil action against the record requester. Should this happen, the court may award the following: actual damages of not less than $2,500.00, punitive damages, reasonable attorney fees, other litigation costs and other preliminary and equitable relief as the court determines to be appropriate.
In addition, Kansas law (K.S.A. 45-215 et seq) prohibits any list of names and addresses derived from public records to be sold, given or received for the purpose of selling or offering for sale any property or service.
I declare that I am eligible and have the express authority to sign for and receive the requested information pursuant to the Federal Drivers' Privacy Protection Act of 1994, as amended. I further declare that any personal information I receive will not be used to sell or offer for sale any property or service.
Subscriber Signature: _______________________________ Date: _______________________
(Please initial one or more applicable codes)
___A. I am requesting my own record.___B. I have written consent from the individual to whom the requested information pertains, to obtain records on their behalf.___C. I work for or am acting on the behalf of a government agency and am requesting this information to fulfill the functions of that agency.___D. I am requesting this information 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.___E. I am an employee, agent or contractor of a legitimate business. I am requesting record information in order to verify the accuracy of personal information submitted by the individual in question. If the information I have is incorrect, I am requesting to obtain corrected information. This information will be used to pursue legal remedies against or recover on a debt or security interest against the individual in question.___F. I am going to use this information in connection with a civil, criminal, administrative, or arbitral proceeding in a Federal, State, or local court or agency or before a self-regulatory body. This may include 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.___G. I am involved in a research project to produce statistical reports. The personal information obtained will not be published, redisclosed or used to contact the individual in question.___H. I am an agent, employee or contractor for an insurer; an insurance support organization or I am self-insured. The information requested will be used in connection with a claims investigation, antifraud activities, rating or underwriting.___I. I am requesting record information to provide notice to owners of towed or impounded vehicles.
___J. I work for a licensed private investigative agency or a licensed security service. (See section II on the Certificate of Acceptable Use).
___K. I am an employer or an agent or insurer working on the behalf of an employer of licensed commercial drivers. I am requesting records information in order to obtain or verify information relating to a holder of a commercial driver's license.
___L. I am requesting records of individuals who have given the state the express consent to release personal information by "opting in" their records.
___M. I will use the information requested in a manner that is specifically authorized by Kansas law and is related to the operation of a motor vehicle or public safety. (See section III on the Certificate of Acceptable Use)
Complete this form including signature and data and mail original to:
Information Network of Kansas
534 South Kansas Avenue, Suite 1210
Topeka, KS 66603-3434