DPPA PERMISSIBLE USES ONLINE FORM

DPPA PERMISSIBLE USES ONLINE FORM
Based upon the federal Driver's Privacy Protection Act (DPPA), this Permissible Uses Form must be completed before the Waukesha County Sheriff's Department can release incident reports or other records containing personally identifiable information or certain vehicle information from a DMV source. Knowledge of what access and uses are permitted under the DPPA is the responsibility of the records requester. The federal law can be found at 18 USC Sec 2721.

SECTION I. REQUESTER INFORMATION:
First and Last Name of Person Requesting the record
Firm/Corporation
Phone Number
Street Address
City, State and Zip Code
Requestor Email
Optional but required to receive a copy of the submitted form.
How will report be provided?*

I will pick up the incident report or other record in person when it is available.Mail the incident report or other record to me at the above address.I authorize the below person to pick up the incident report or other record on my behalf.
Name of person authorized to pick up Incident Report.
SECTION II. RECORD INFORMATION SHEET
Date of Incident

MonthDayYear
Location of Incident
Incident Report Number, if known
Other information to describe incident:
The Driver's Privacy Protection Act allows for civil and criminal penalties for improperly obtaining, disclosing, or using personal information from an incident report or other record. or information that was acquired through the Wisconsin Division of Motor Vehicles (DMV) for purposes other than as stated in this form.

I am authorized under the DPPA to obtain the identified report or other record based upon the following permissible uses (check all applicable boxes):
Permissible Uses:

1. For use by any government agency. including any court or law enforcement agency. in carrying out its functions.2. For use in connection with matters of a 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 to: (a) verify the accuracy of the personal information submitted by the individual to the business. and (b) to obtain correct information if the information as so submitted is not correct or is no longer correct, but only for purposes of preventing fraud, pursuing legal remedies against, or collecting a debt or security interest against the individual.
If option 3 selected, name of 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 any insurer or insurance support organization, or by a self-insured entity, or its agents, employees or contractors in connection with claims investigation activities, rating or underwriting.7. For use in providing notice to the owners of towed or impounded vehicles.8. For use by any licensed private investigative agency or licensed security service if the vehicle record or driver record is being requested for those purposes permitted under the Driver's Privacy Protection Act.
If option 8 selected, name of individual:
Identification of vehicle:
9. For use by an employer or its agent or insurer to obtain or verify information relating to a holder of a commercial driver license (CDL) that is required under Chapter 313 of Title 49.10. For use in connection with the operation of private toll transportation facilities.11. For any other use in response to requests for individual motor vehicle records if the State has obtained the express consent of the person to whom such personal information pertains.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.13a. For use with the consent of the person to whom the personal information pertains. I am requesting a copy of my own record.13b. I am a parent or legal guardian of a minor child and I am requesting a copy of his/her record. Name the minor child below.13c. I am requesting the record of another person and have attached the written consent of the person or persons about whom the personal information pertains. You MUST attach a written and notarized consent statement from each other person when submitting the form. Name of other person or persons giving consent below.14. For any other use specifically authorized under Wisconsin law, if such use is related to the operation of a motor vehicle or public safety. State the specific authorization under Wisconsin Law below.
If 13b selected, name of minor child:
If 13c selected, name of other person or persons giving consent:
If 14 selected, name the specific authorization under Wisconsin law:
I certify that the information and statements on this form are true and correct, comply with the provisions of the Federal Driver's Privacy Protection Act 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.
(Requester Signature)

Clear
(Print Requester Name)
Please verify that you are human*
Should be Empty: