Free 53789.pdf - Indiana

REQUEST FOR DRIVING RECORDS AND/OR MOTOR VEHICLE OR WATERCRAFT RECORDS
State Form 53789 (11-08) Approved by State Board of Accounts, 2008 BUREAU OF MOTOR VEHICLES

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The records that the Indiana Bureau of Motor Vehicles maintains are open to the public, except as provided by law. Recipients of records must comply with various legal requirements pertaining to, but not limited to, their use and record keeping. Recipients are required to know and comply with all of the legal requirements pertaining to the records. "Personal information means information that identifies a person, including an individual's: (1) digital photograph; (2) Social Security number; (3) driver's license or identification document number; (4) name; (5) address (but not the 5-digit zip code); (6) telephone number; or (7) medical or disability information." I.C. § 9-14-3.5-5. All records will contain only the personal information that the requesting party submitted with their request unless laws permit the party to obtain records containing additional personal information. Step 1: Check the box in front of the category that describes your reason for requesting the information in the motor vehicles records, and provide any additional information required for that category. Please mark only one (1) category per form. I am the person named in the requested records requesting records containing personal information. I am a legal guardian or have power of attorney for the person named in the requested records containing personal information. *Must provide a copy of the documents granting guardianship or power of attorney. I have the permission of the person named in the requested records containing personal information. *Must provide release document with the notarized authorization from the person, or the person's signed release document and a copy of the person's driver's license or identification card. I am a law enforcement officer requesting records containing personal information to use for investigation purposes. Badge number: ____________________________; Law enforcement agency: ________________________________________ I am an attorney requesting records. Attorney number: __________________________________________ *To obtain records containing additional personal information, an attorney must submit a Third Party Request for Records. I am an elected government official or a government employee requesting records that (select one) do or do not contain more personal information than what I am providing with this request. Government position: __________________________________; Government entity: __________________________________; Intended use of the records: ________________________________________________________________________________. I am a member of the media requesting records. *Records will not contain any personal information besides what is submitted with the request. All others. *Records will not contain any additional personal information. Note: You may obtain information in motor vehicle records through additional sources including by establishing a MyBMV account, subscribing to IN.Gov (AccessIndiana), or in limited circumstances, by entering into an agreement with the Bureau of Motor Vehicles. If you have any questions, please call (317) 233-6000. Step 2: Complete one of the following sections: A. Requesting a driving record for the following person:
Name of driver (first name, middle name, last name) Driver's Social Security Number, if known * Driver's last address, if known (number and street, city, state, and ZIP code) Driver's Indiana driver's license or identification card number Driver's date of birth (mm/dd/yyyy)

Check the box next to the type of record you are requesting and provide the required information. Driver's driving record (ODR/MVR) fee: $4.00. Please allow approximately 7-10 working days to process this request.
Location of accident (number and street, city, state) Name of insured driver Name of other driver involved in accident Date of accident or ticket (mm/dd/yyyy)

SR 21-Proof of insurance at the time of an accident or ticket fee: $4.00. This information is available approximately 120 days after the date of an accident or a ticket. Driver's license history fee: $8.00. This is a driver's driving record plus photocopies of specified underlying documents. Depending on the documents requested, please allow approximately 2-8 weeks to process this request. Specify the documents being requested: ________________________________________________________________________ Certification of record fee: $4.00 per record certified. The certification accompanies the record. TOTAL DUE: $______________. Make money order payable to: Indiana Bureau of Motor Vehicles. Anyone with a valid and nonsuspended Indiana driver's license or identification card may pay by a check made payable to: Indiana Bureau of Motor Vehicles.

B. Requesting a motor vehicle record for the following vehicle:
Vehicle year Vehicle plate number Vehicle identification number Vehicle type Plate type Name of registrant, if known Vehicle make Vehicle model Plate issue year

Registrant's last address, if known (number and street, city, state, and ZIP code)

Check the box next to the type of record you are requesting. Title inquiry fee: $4.00. This record contains information pertaining to the current owner and includes information regarding liens; vehicle make, model, year, and VIN; odometer reading; and vehicle purchase date. Please allow approximately 2-8 weeks to process this request. Title history fee: $8.00. This record contains information pertaining to all prior Indiana owners of the vehicle for the prior ten (10) years, or the prior five (5) years if no changes were made to the title during that prior five (5) year period. Please allow approximately 2-8 weeks to process this request. Registration inquiry fee: $4.00. ( Check this box if you also need insurance information, which will be provided for no additional fee. However, gathering that information will delay completing the processing of your request.) This record contains information pertaining to the current Registrant and includes county and township of registration; registration fees and county tax paid; vehicle purchase date; vehicle make, model, year, VIN, type and color; and plate number with expiration date. Please allow approximately 2-8 weeks to process this request. Registration history fee: $8.00. Contains the above information for the prior four (4) years. Please allow approximately 2-8 weeks to process this request. Certification of record fee: $4.00 per record certified. The certification accompanies the record. TOTAL DUE: $______________. Make money order payable to: Indiana Bureau of Motor Vehicles. Anyone with a valid and nonsuspended Indiana driver's license or identification card may pay by a check made payable to: Indiana Bureau of Motor Vehicles. C. Requesting a watercraft record for the following watercraft:
Watercraft year Motorboat registration number Watercraft make Watercraft model Hull identification number Name of registrant, if known

Registrant's last address, if known (number and street, city, state, and ZIP code)

Check the box next to the type of record you are requesting. Sales tax verification fee: $8.00. This letter informs the reader that the owner paid sales tax in Indiana for a particular watercraft. Please allow approximately one week to process this request. Certification of record fee: $4.00 per record certified. The certification accompanies the record. TOTAL DUE: $______________. Make money order payable to: Indiana Bureau of Motor Vehicles. Anyone with a valid and nonsuspended Indiana driver's license or identification card may pay by a check made payable to: Indiana Bureau of Motor Vehicles. Step 3: The person submitting the form must provide their information for the following:
Name of person or business (first name, middle name, last name) Mailing address (number and street, city, state, and ZIP code)

A person who is requesting their own information; or has guardianship, power-of-attorney, or notarized written permission authorizing the person making the request to receive another person's records containing personal information must provide the following additional information:
Indiana driver's license number (DLN) or identification (ID) card number (People without an Indiana DLN or ID must include a photocopy of their out of state driver's license or identification card.) Last 4 digits of Social Security Number (This information is used for security purposes only.)

X X X ­ X X ­ ____________ Step 4: Sign and date the form. I swear or affirm under the penalties of perjury that all of the information on this form is true and accurate.
Signature Date (month, day, year)

Step 5: Deliver form and payment to a Bureau of Motor Vehicles license branch, or mail form and payment to: For driving records: Indiana Bureau of Motor Vehicles, Attn: Driver Records Requests, Indiana Government Center North, 100 North Senate Avenue, Room N405, Indianapolis, IN 46204 For vehicle or watercraft records: Indiana Bureau of Motor Vehicles, Attn: Driver Records Requests, Indiana Government Center North, 100 North Senate Avenue, Room N404, Indianapolis, IN 46204 For BMV Use Only
Name of BMV customer service representative Branch or central office department Date (month, day, year)