Form Dl-503 - Request For Driver Information
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2DL-503 (10-17)
REQUEST FOR DRIVER INFORMATION
DO NOT SEND CASH • SEE REVERSE FOR INSTRUCTIONS
Bureau of Driver Licensing • P.O. Box 68695 • Harrisburg, PA 17106-8695
CHECK (✔) ONE ONLY:
FULL HISTORY: $10.00 FEE
❑
BASIC INFORMATION: $10.00 FEE (Driver history is not included)
CERTIFIED DRIVER RECORD: $34.00 FEE
❑
❑
3 YEAR DRIVER RECORD: $10.00 FEE
COPY OF DOCUMENT FROM FILE (MICROFILM): $10.00 FEE
❑
❑
10 YEAR DRIVER RECORD: $10.00 FEE (Employment Purposes Only)
CERTIFIED COPY OF DOCUMENT FROM FILE: $34.00 FEE
❑
❑
You may obtain a copy of your own 3 year or 10 year Driving Record on PennDOT'S website at
A
REQUESTER INFORMATION
B
END USER OF INFORMATION BEING REQUESTED
NAME/COMPANY
NAME/COMPANY
ADDRESS
ADDRESS (P.O. Box not acceptable), need to provide physical location of business/residence
P.O. Box number may be used in addition to the actual address, but cannot be
used as the only address.
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
DAYTIME TELEPHONE NUMBER (REQUIRED) _________________________________
DAYTIME TELEPHONE NUMBER (REQUIRED) _____________________________________
______________________________________
RELATIONSHIP TO DRIVER (REQUIRED) _____________________________________________
RELATIONSHIP TO DRIVER (REQUIRED)
D
AFFIDAVIT OF INTENDED USE
Intended Use of the Information Requested: CHECK ONLY ONE
X
SIGNATURE
❏
B = Driver Release (Driver must complete Section E.)
NOTARIZATION NOT REQUIRED WHEN REQUESTING YOUR OWN RECORD
❏
C = Credit Business (Legitimate Business need in connection with a business
C
transaction initiated by the driver.)
DRIVER INFORMATION
❏
C = Credit Potential Investor, Server or Current Insurer (In connection
NAME:
LAST
FIRST
INITIAL
with an assessment of the credit/payment risks associated with an existing credit
obligation.)
ADDRESS
❏
E = Employment (To support the hiring or the continuation of employment. Driver
must complete Section E.)
❏
CITY
R = Insurance Company requesting record of person it intends to insure,
now insures, or has rejected for insurance.
❏
K = Court Order must be attached. (A subpoena issued in compliance with
STATE
ZIP CODE
Pa. R.C.P. 4009.21 will be accepted in lieu of a court order).
❏
L = Attorney representing driver identified in Section C (Driver must complete
PHONE NUMBER
Section E.)
I hereby Certify that _______________________________________________
DATE OF BIRTH
DRIVER NUMBER
PRINTED NAME OF REQUESTER
MONTH
DAY
YEAR
will use the driver record abstract(s) required pursuant to Section 6114
of the Pennsylvania Vehicle Code, for the purpose checked above only
and no other reason. This affidavit is filed in compliance with Section
E DRIVER RELEASE
607 of the Fair Credit Reporting Act. I/We have read and signed this
form after its completion, and I/We swear or affirm that the statements
I _______________________________________ hereby request
made herein are true and correct, and that any statement made on or
NAME OF DRIVER
pursuant to this form is subject to the penalties of 18 Pa C.S. Section
the Department of Transportation to furnish a copy of my PA Driver's
4903(a)(2) (relating to false swearing), which shall include punishment
Record to ____________________________________________
of a fine not exceeding $5,000, or to a term of imprisonment of not more
NAME OF PERSON/COMPANY
than two years, or both.
X
X
SIGNATURE OF DRIVER
DATE
_______________________________________________________________
SIGNATURE OF REQUESTER
F MICROFILM
Title ___________________________________________________________
TYPE OF DOCUMENT
DATE OF VIOLATION
SUBSCRIBED AND SWORN
TO BEFORE ME:
MONTH
DAY
YEAR
(see list of available documents below)
X
Documents Available:
SIGNATURE OF PERSON ADMINISTERING OATH
• Citations
• Ignition Interlock Removal Letter
• Court Certifications
• Suspension/Revocation Letters
S
• Applications
• Restoration Letters
• License Renewals
• Rescind Letters
E
• Judgments
• Department Hearing or Exam Notice
A
SIGN IN PRESENCE OF NOTARY
• Suspension Credit Affidavits
L
MESSENGER NO.
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