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    Crash Record Request Form

    Uploaded by

    itbecourtney
    The document provides information about requesting a crash report from the Minnesota Department of Public Safety. It includes a form to request crash reports with fields for crash details, requester information, and a Tennessen warning about the purpose and use of the provided data.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Crash Record Request Form

    Uploaded by

    itbecourtney
    6 views1 page
    The document provides information about requesting a crash report from the Minnesota Department of Public Safety. It includes a form to request crash reports with fields for crash details, requester information, and a Tennessen warning about the purpose and use of the provided data.

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    Minnesota crash record request form

    Original Title

    CrashRecordRequestForm

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    © © All Rights Reserved

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    The document provides information about requesting a crash report from the Minnesota Department of Public Safety. It includes a form to request crash reports with fields for crash details, requester information, and a Tennessen warning about the purpose and use of the provided data.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    6 views1 page

    Crash Record Request Form

    Uploaded by

    itbecourtney
    The document provides information about requesting a crash report from the Minnesota Department of Public Safety. It includes a form to request crash reports with fields for crash details, requester information, and a Tennessen warning about the purpose and use of the provided data.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    MINNESOTA DEPARTMENT OF PUBLIC SAFETY

    Print Form
    DRIVER AND VEHICLE SERVICES
    Visit us: drive.mn.gov
    (651) 296-2940 or (651) 282-6555 TTY
    MINNESOTA CRASH RECORD REQUEST
    Reports can be obtained in person or by mail at: Please complete form with all required areas, or it will be returned
    Driver and Vehicle Services • $5.00 fee is due for each requested copy or search (when not found)
    445 Minnesota St. Suite 161 • Checks/ Money Orders should be made payable to: Driver and Vehicle Services
    St. Paul, MN 55101-5161 • Requests will not be processed without a signature from an authorized
    requestor
    By Mail: Requester must include a legible copy of driver license, government issued identification card, or notarized signature.

    Crash Information (Print or Type) Law Enforcement Case #

    Person(s) involved (last name, first, middle) Date of Birth Driver License # License Plate #
    1.
    2.

    *Without listing license plate numbers, the requested report may not be located.
    Location of Crash (Street or Highway) County Date of Crash (mm/dd/yyyy)

    Check one box for authorized requestor:


    Driver Passenger Pedestrian Next of Kin Owner of Damaged Property Owner of Vehicle

    Insurance Representative - Client Name Legal Representative - Client Name


    Please note: in the case of a fatality, the next of kin or legal rep. must provide proof of death; death certificate, obituary or memorial card

    Name of Authorized Requestor Company Name

    Data Purchaser Account #

    How would you like to receive the report: Email Mail

    Email report to:

    Address City State Zip Code

    Tennessen Warning
    What is the purpose of supplying the requested information?
    • The information collected on this form is to process your request for a copy of a crash record pursuant to 18 U.S.C. § 2721 and Minn. Stat. §169.09.
    Am I required to provide the requested information?
    • You must provide the information requested in order to obtain a copy of the crash record.
    What will happen if I do not provide the requested information?
    • If you do not provide the requested information, DVS will be unable to process your crash record request.
    Who will have access to the information I provide?
    • DVS may disclose personal information when it relates to the operation or use of a vehicle or to public safety. The use of personal information relates
    to public safety if it concerns the physical safety or security of drivers, vehicles, pedestrians, or property. The personal information you provide to
    request a crash report is classified by 18 U.S.C. § 2721 and Minn. Stat. § 171.12 and is subject to the disclosure in accordance with these laws.

    I(we) certify that the information and statements on this request are true and correct, and comply with the provisions of Minn. Stat. §169.09(8). I (we) understand
    that disclosing any information contained in any crash report, except as provided in Minn. Stat. §§169.09(13), 13.82(3)or(6), or other statutes is a misdemeanor.

    Signature of Authorized Requester:


    Subscribed and sworn before me this ___Day of______, 20___
    Notary Public_______________County________________
    Notary Signature_________________________________ Notary Stamp

    My Commission Expires____________________________
    Office Use Only: Comments no file(s) located Search made - No police report available
    PS2503-15 (11/2020

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