Fillable Form Dl-135 - Request For Vehicle Information printable pdf download

DL-135 (6-15)

request for vehicle information

$9.00 Fee required for each record requested or $32.00 Fee for each certified record

The most current version of this form can be found at

PRINT OR TYPE ALL INFORMATION LEGIBLY • DO NOT SEND CASH

SEE REvERSE FOR INSTRuCTIONS / INFORmATION

REQuESTER INFORmATION

ENd uSER OF INFORmATION BEING REQuESTEd

NAME

NAME OF BUSINESS

ADDRESS: P.O. Box number may be used in addition to the actual address, but cannot

ADDRESS: (P.O. Box not accepted), need to provide physical location of business/residence

be used as the only address.

CITY

STATE

ZIP CODE

CITY

STATE

ZIP CODE

DAYTIME TELEPHONE NUMBER (Required)

REFERENCE NUMBER

CONTACT PERSON

PHONE #

NAIC NUMBER

POLICY NUMBER

CLAIM NUMBER

SIGNATURE

mICROFILm

Certified - ❏ YES

($32.00 Required)

NOTARIZATION NOT REqUIRED wHEN REqUESTING YOUR OwN RECORD

vEhICLE INFORmATION

CHECk (✔) ONE ONLY: see reverse side for explanation of information you will receive.

(read instructions for number 2 on the back of the form)

❏ TITLE - CURRENT RECORD

❏ ODOMETER - CURRENT RECORD

TAG NUMBER

TITLE NUMBER

❏ TITLE - PREvIOUS RECORD

❏ ODOMETER - PREvIOUS RECORD

❏ ENCUMBRANCE ❏ INSURANCE

❏ OTHER _____________________

vEHICLE IDENTIFICATION NUMBER

DATE OF ACCIDENT (if applicable)

vEhICLE OWNER RELEASE

NAME

I ___________________________________________________________________________

NAME OF vEHICLE OwNER

hereby request the PA Department of Transportation to furnish a copy of my PA vehicle record to,

ADDRESS

NAME OF REqUESTER

CITY

STATE

ZIP CODE

____________________________________________________________________________

SIGNATURE OF vEHICLE OwNER

DATE

AFFIdAvIT OF INTENdEd uSE - YOu muST ChECk (✔) ONE ITEm

�� 1. For use by any government agency, including any court or law enforcement agency, in carrying out its functions, or any private person or entity

acting on behalf of a Federal, State, or local agency in carrying out its functions.

�� 2. For use 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.

�� 3. For use in the normal course of business by a legitimate business or its agents, employees, or contractors, but only:

a. to verify the accuracy of personal information submitted by the individual to the business or its agents, employees, or contractors; and

b. if such information as so submitted is not correct or is no longer correct, to obtain the correct information, but only for the purposes of preventing

fraud by, pursuing legal remedies against, or recovering on a debt or security interest against, the individual.

�� 4. For use in connection with any civil, criminal, administrative, or arbitral proceeding in any Federal, State, or local 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, or local court.

�� 5. For use in research activities, and for use in producing statistical reports, so long as the personal information is not published, redisclosed, or

used to contact individuals.

�� 6. For use by an insurer or insurance support organization, or by a self-insured entity, or its agents, employees, or contractors, in connection with

claims investigation activities, antifraud activities, rating or underwriting.

�� 7. For use in providing notice to the owners of towed or impounded vehicles.

�� 8. For use in connection with the operation of private toll transportation facilities.

SUBSCRIBED AND SwORN

TO BEFORE ME:

MONTH

DAY

YEAR

will

I hereby certify that __________________________________________________

NAME OF REqUESTER

use the vehicle information requested pursuant to Section 6114 of the Pennsylvania vehicle Code, for the

SIGNATURE OF PERSON ADMINISTERING OATH

purpose checked above only and for no other reason. This affidavit is filed in compliance with Section 607

of the Fair Credit Reporting Act and the Federal Drivers Privacy Protection Act. I/we state that I/we have

read and signed this form after its completion, and I/we swear or affirm that the statements made herein

are true and correct, and that any statement made on or pursuant to this form is subject to the penalties

of 18 PA C.S. Section 4903(a)(2) (relating to false swearing), which shall include punishment of a fine not

exceeding $5,000, or to a term of imprisonment of not more than two years, or both.

SIGNATURE OF REqUESTER

TITLE OF REqUESTER (if applicable)

ThIS FORm mAY BE PhOTOCOPIEd

mESSENGER NO.

Form Dl-135 - Request For Vehicle Information

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