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Requester, please note: Under Wisconsin law a request for access to a public record “is deemed sufficient if it reasonably describes the requested record or the information requested.” However, “a request for a record without a reasonable limitation as to subject matter or length of time represented by the record does not constitute a sufficient request.” (See State Statute 19.35(1)(h), Wis Stats.
PURSUANT TO SEC. 19.35 (4) (B), WIS STATS, YOU ARE HEREBY NOTIFIED THAT IF YOUR REQUEST WAS MADE IN WRITING AND DENIED IN WHOLE OR IN PART, YOU HAVE A RIGHT TO REVIEW BY “WRIT OF MANDAMUS” OR UPON APPLICATION TO THE DISTRICT ATTORNEY, OR ATTORNEY GENERAL.
I/We are authorized under the Federal Driver’s Privacy Protection Act to obtain the identified accident/incident report and personal information based upon the following (mark ALL applicable boxes):
If requesting the record of another person, please upload notarized consent:
For use in connection with matters of a 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 to carry out the purposes of the Automobile Information Disclosure Act, the Anti-Car Theft Act of 1992 and the Clean Air Act.
A government agency (federal, state, local or tribal) or employed by such, for the purposes of the government agency to carry out its official functions.
A federal, state, circuit, local or tribal court, or employed by such, for the purposes of the court to carry out its official functions.
A Wisconsin or out-of-state law enforcement agency, or employed by such, for the purpose of the law enforcement agency to carry out its functions.
Authorized representative, agent, contractor, or employed by such, of a legitimate business and the vehicle/driving record being requested will be used for normal course of business, but only to (a) verify accuracy of the personal information; or (b) obtain correct information, but only for purposes of preventing fraud, pursuing legal remedies, or collecting a debt.
Authorized for use in connection with any civil, criminal, administrative, or arbitral proceedings in any federal, state, circuit, local, or tribal 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, circuit, local, or tribal court.
Please list client's name:
Authorized for use in research activities and producing statistical reports, as long as the personal information is not published, re-disclosed, or used to contact individuals.
Please Include a date range for your request:
Please describe the kind/nature of your research:
Authorized representative, agent, contractor, or employed by such, of an insurer, insurance support organization or self-insured entity and the vehicle/driving record(s) being requested will be used only in connection with the following: (a) claims investigation; (b) anti-fraud activities; (c) rating or underwriting.
Authorized for use in providing notice to the owners of towed or impounded vehicles.
Authorized representative or owner of a licensed private investigative agency or licensed security service and the vehicle/driving record is being requested for the use of purposes permitted under the Federal Driver’s Privacy Protection Act.
Authorized as an employer, or its agent or insurer for use in obtaining or verifying information relating to a holder of a commercial driver license (CDL).
Authorized representative or owner of a private toll transportation facility for use in the operation of the facility.
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 vehicle or public safety.
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.
I agree that the use of the records I have requested is specifically authorized under the laws of the State of Wisconsin and the DPPA and that my intended use of the records is related to the operation of a motor vehicle or public safety or for other use as identified above.
I certify that the information and statements on this request are true and correct and understand that the unauthorized disclosure of information obtained from these records for a purpose other than stated on this request form, or the sale or other distribution of the information to a person or organization not disclosed in this request, may result in civil and criminal penalties imposed under Title 18 U.S.C. Section 2724.
I further understand that I have the right to request a mandamus review of the responses provided to this request under Wisconsin Statute Section 19.37(1).
If any exceptions number 2-14 are checked, requestor is required to pick up the records in person and provide a signature at time of pickup.
YES ___________ (initials)
NO ____________ (initials)
This field is not part of the form submission.
* indicates a required field