Free BDVR-155 Record Lookup Request for Governmental Agencies - Michigan


File Size: 134.5 kB
Pages: 2
Date: February 26, 2008
File Format: PDF
State: Michigan
Category: Secretary of State
Author: Michigan Department of State - JoAnne Romanek
Word Count: 982 Words, 6,619 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.michigan.gov/documents/BDVR-155__06-03_69637_7.pdf

Download BDVR-155 Record Lookup Request for Governmental Agencies ( 134.5 kB)


Preview BDVR-155 Record Lookup Request for Governmental Agencies
MICHIGAN DEPARTMENT OF STATE RECORD LOOKUP REQUEST FOR GOVERNMENTAL AGENCIES
Section 1. Requestor's Information (Please print or type all information.)
Governmental Agency Name Representative's Name and Title

Clear Form

If you are not requesting information for a Governmental Agency, use form BDVR-153 if requesting your own record, or form BDVR-154 if you are requesting records on someone other than yourself.

Mailing Address

File or Claim Number

City

State

Zip Code

Daytime Telephone Number

(
Section 2. Michigan Department of State Account Number
To my knowledge, this agency has not been assigned a Michigan Department of State Account Number. A cover letter on the Agency letterhead is enclosed, requesting an account number be issued for current and future use.

)

-

Michigan Department of State Account Number ______________________________________

Certified record(s) needed Section 3. Driver Information (If you only want a driving record, leave Section 4 blank.)
Check boxes that apply: Driving Record for:
(Shows last reported address)

Employment, Credit, or Insurance Court Other: ________________________________

Current Application Application History For partial histories, please complete: from ______/______/______ to ______/______/______ Address History Other Driving-Related Record(s) ___________________________________________________ Date ______/______/______
(Hearing, Offense, License Status, etc.)

Driver's Full Name (First, Middle, Last) Driver's Full Name (First, Middle, Last)

Driver's License Number Driver's License Number

Date of Birth Date of Birth

Section 4. Registration or Title Information (Insurance information is not retained and is not available.)
License Plate or Vehicle Registration Number Year Make and Model Vehicle or Hull Identification Number

Check boxes that apply: Current Vehicle Owner and Lienholder Information Registration Information as of ____/____/____ Copy of Current Title Application and Related Forms Complete Title History Complete Registration History Partial Title History For partial histories, please complete: from ______/______/______ to Partial Registration History Check box if you want: All motor vehicles registered or titled to this owner.* All other registered or titled assets for the owner indicated.* Vehicle Owner(s) Name Vehicle Owner(s) Address City State Zip Code

______/______/______

For Office Use Only
BDVR-155-WEB (02/08)

SECTIONS 1, 2 AND 5 MUST BE COMPLETED IN ORDER TO PROCESS YOUR REQUEST FOR RECORDS

Section 5. Requestor Certification (This section must be completed or request will not be processed.)
I certify that this requested record information is for use by a federal, state, or local governmental agency, including a court or law enforcement agency in carrying out the agency's functions. I also certify that the information and statements on this request are true, correct, and comply with the provisions of state and federal driver privacy laws. I understand that the willful unauthorized disclosure of personal information obtained from these record(s) for a purpose not outlined by my government employing agency, or the sale or other redisclosure of information to a person or organization not identified in this request, may result in penalties imposed under MCL 28.295a, 257.902, 257.903, 324.80130d, 324.80319a, 324.81120, 324.82160 and other provisions of law.

X___________________________________________
Signature of Requestor ­ form must be signed or request will not be processed.

____ / ____ / ____
Date

Penalties for Misuse: Under Michigan law, a person who makes a false representation or a false certification to obtain personal information or who uses personal information for a purpose other than a permissible purpose identified in law is guilty of a felony, which may be punishable by imprisonment for up to 5 years and/or a fine of up to $5,000. Subsequent convictions may result in imprisonment for up to 15 years and/or a fine of up to $15,000.

INSTRUCTIONS FOR COMPLETING THIS FORM
Fill out as much information about your request as you can. Accurate and complete information will help us locate the record(s) you want. Records will only be mailed to the address listed on your Michigan Department of State account. Please include a daytime telephone number in case we have questions about your request. Government agencies that do not have a Michigan Department of State account number need to enclose a cover letter on agency letterhead, along with this request form, requesting that an account number be issued for current and future use. A cover letter will not be necessary if you already have a Michigan Department of State account number documented in Section 2 of this request form. For driving records, include as much detail in Section 3 as possible. If you just need the name, address, or driving status, request the current record only. If you only want a driving record, do not complete Section 4. Personal identification card information is also available. Complete Section 3, Driver Information, substituting the identification card number for the driver's license number. For vehicle information, include as much detail as possible. The owner's name should be the owner of record, not a purchaser who has not yet titled the vehicle. If you just need name, address, or ownership verification, request only a registration record. Information about proof of insurance at vehicle registration is not retained and is not available. For watercraft, snowmobile, ORV, or mobile home records, complete Section 4, Registration or Title Information, substituting the watercraft or snowmobile registration number for the license plate number or substituting the mobile home serial number for the vehicle identification number. Include as much information as you can about the watercraft, snowmobile, ORV, or mobile home. * When requesting records for all motor vehicles or all assets registered and/or titled through the Michigan Department of State for individuals and/or companies, precise information is required. Information retrieved is based upon an exact name and address match. The individual's name and address, as provided by the record requestor, must match the name and address on the record(s) held by the Michigan Department of State.

Mail your completed request to: Michigan Department of State Record Lookup Unit 7064 Crowner Drive Lansing, Michigan 48918-1540 Read the instructions for guidance or call 517.322.1624 for help in completing this form. Completed requests may be faxed to 517.322.1181.

www.Michigan.gov/sos

BDVR-155-WEB (02/08)