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Record Request

* indicates a required answer.

FEDERAL DRIVER PRIVACY PROTECTION ACT PERMISSIBLE USES FORM

Based upon the Federal Driver's Privacy Protection Act, this Request must be completed before information containing personally identifiable information in the Police Report can be released without redaction.  Knowledge of what access and uses are permitted under the listed Federal Act is the responsibility of the Requester.  


SECTION I. REQUESTER INFORMATION

1. *

Name of person completing form:

2.

Firm/Corporation:

3. *

Phone number:

4. *

Street address:


SECTION II. RECORD INFORMATION SHEET

5. *

Date of Accident/Incident:

6. *

Location of Accident/Incident:

7.

Party Name to the Accident/Incident:


SECTION IIl. AUTHORIZATION

The Driver's Privacy Protection Act is enforced by the United States Department of Justice, which may seek civil and criminal penalties for improperly obtaining, disclosing, or using personal information from an accident report or other police record, or the information was acquired through the Wisconsin Department of Transportation System and it is determined that these records are used for purposes other than as stated in this request.

I/We are authorized under the Federal Driver's Privacy Protection Act to obtain the identified accident/incident report and personal information based upon the following (mark all applicable boxes:)

8.

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

 
yes
9.

(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 or 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.  

 
yes
10.

(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.  

 

 

 
yes
11.

(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 or process, investigation in anticipation of litigation, and the execution or enforcement of judgments or orders, or pursuant to an order of a Federal, State, or local court.  

 
yes
12.

(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. 

 
yes
13.

(6)  For use by any insurer support organization, or by a self-insured entity, or its agent, employees, or contractors, in connection with claims investigation activities, antifraud activities, rating or underwriting.  

 
yes
14.

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

 
yes
15.

(8)  For use by any licensed private investigative agency or licensed security service for any purpose permitted under this subsection.  

 
yes
16.

(9)  For use by an employer or its agent to insurer to obtain or verify information relating to a holder of a commercial driver's license that is required under chapter 313 of title 49.

 
yes
17.

(10)  For use in connection with the operation of private toll transportation facilities.  

 
yes
18.

(11)  For any other use in response to requests for individual motor vehicle records if the State has obtaining the express consent of the person to whom such personal information pertains.  

 
yes
19.

(12)  For bulk distribution for surveys, marketing or solicitations if the State has obtained the express consent of the person to whom such personal information pertains.  

 
yes
20.

(13)  For use by any requester, if the requester demonstrates it has obtained the written consent of the individual to whom the information pertains.  

 
yes
21.

(14)  For any use authorized under Wisconsin law specifically Wisconsin Stat. 346.70(4)(f) which provides that any person may with proper care, during office hours, and subject to such orders or regulations as the custodian thereof prescribes,, examine or copy such uniform traffic accident reports, including supplemental or additional reports, statements of witnesses, photographs and diagrams, retained by local authorities, the state traffic patrol or any other investigating law enforcement agency.  Release of these reports is permissible since the Wisconsin Court of Appeals, New Richmond News v. City of Richmond, 2014 AP 1938 (Ct. App. 5/10/2016, publication recommended), has decided such use is related to the operation of a motor vehicle or public safety, and can be released without redaction.  

 
yes

Certification

I/We certify that the information and statements on this request are true and correct, comply with the provisions of the Federal Driver's Protection Acct and understand that the willful, unauthorized disclosure of information obtained from these records for a purpose other than stated on this request, or the sale or other distribution of the information to a person or organization not disclosed in this request may result in civil and criminal penalties imposed under Title 18 U.S.C. Section 2724.  I/We will also defend, indemnify, and hold harmless the City of Waupun and it's employees or agents from all claims, actions, damages, or losses, arising from my/our representations made in the execution of this form, whether said representations were negligently or intentionally made to said City.  

22. *

Requester Typed Signature

23. *

Date Signed

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