Free Pledge of Confidentiality - Wisconsin

PLEDGE OF CONFIDENTIALITY
MV3454 9/2003 s.343.16(5)(d) Wis. Stats.

Wisconsin Department of Transportation

Clear form

Section 1 Completion of this Pledge of Confidentiality indicates that you have information, which questions a person's ability to safely operate a motor vehicle. It also indicates that you will not disclose the information to the Wisconsin Department of Transportation, including the driver's name, without a Pledge of Confidentiality. This pledge will remain confidential to the extent permitted by law. A court of competent jurisdiction could order the release of information otherwise held in confidence as a result of this pledge. To be valid, this Pledge must be signed by a Wisconsin Department of Transportation representative prior to receiving the personally identifiable information about the driver. Information provided prior to completion of this Pledge, or not listed in this Pledge, or any subsequent information that is not identified in a Pledge of Confidentiality Agreement will not be considered confidential. Section 2 - To be completed by the Information Source
Name of Information Source Address City Area Code - Telephone Number

Please give the reason the information will not be provided without a pledge of confidentiality.

(Information Source Signature)

Section 3 - To be completed by a DOT Representative I have determined that a Pledge of Confidentiality is necessary to obtain potentially important information related to public safety. I extend the Department's Pledge to the above-named information source.

(DOT Representative Signature)

Section 4 - To be completed after the pledge is signed by a DOT Representative
Name of Driver Address City Driver Identification Number

Form MV3141, Driver Condition Behavior Report MUST be attached.