HireRight, LLC - Confidential R.09.29.20 Exhibit 5 – NH DSMV 505
New Hampshire Employment Release
(FORM DSMV 505)
Exhibit 5
New Hampshire requires the attached NH RELEASE OF MOTOR VEHICLE RECORDS
FORM DSMV 505 to be completed and notarized PRIOR to submitting a NH MVR request.
THIS FORM MUST BE COMPLETED IN ITS ENTIRETY (and Notarized) AND MAINTAINED FOR A
MINIMUM OF TWO YEARS (from the date of the last MVR request) BY THE
EMPLOYER, REGARDLESS OF WHETHER OR NOT THE INDIVIDUAL WAS HIRED BY
YOUR COMPANY.
Below are the steps for completing the release.
STEP 1: Driver Information
• Checkmark “Driver record, certified copy.
• Disregard the referenced charge. HireRight will bill you the state fee.
STEP 2: Who Are you?
• Checkmark “I AM NOT THE RECORD HOLDER”. The driver should complete the
section listed under “Whose information are you looking for (the record holder’s
information” with the driver’s information.
STEP 3: Information of the person filling out this form (the requestor):
• This section should be completed by the company requesting the record.
• The report will not be mailed. It will be returned electronically to you.
STEP 4: Notary Public or Justice of the Peace Acknowledgement:
• The document must be signed by both, the driver and the notary public.
• BOTH DATES MUST MATCH
STEP 5: Intended Use of Information – Mark only if ordering for CDL purposes.
• Checkmark option, “By an employer or its agent or insurer”
***If ordering for NonCDL purposes, leave blank
STEP 6: IMPORTANT!!! Please read the penalty clause
STEP 7: Signature (this step is required)
• Company representative must sign and date
STEP 8: Submit your request
• Please do not submit to the state. Save the document and produce at the time if selected to
participate in New Hampshire driving record audit.
Should you have any questions, please contact Customer Service at 866-521-6995.
Date of birth: ______/_______/__________
Robert L. Quinn
Commissioner of Safety
Elizabeth A. Bielecki
Director of Motor Vehicles
State of New Hampshire
DEPARTMENT OF SAFETY
DIVISION OF MOTOR VEHICLES
STEPHEN E. MERRILL BUILDING
23 HAZEN DRIVE, CONCORD, NH 03305
Telephone: (603)227-4000 TDD Access Relay NH 7-1-1
RELEASE OF MOTOR VEHICLE RECORDS
FORM DSMV 505 (Rev. / )
What information are you requesting from the DMV?
DRIVER
information:
REGISTRATION
information:
TITLE
information:
TICKET, ACCIDENT OR
COURT information:
OTHER
information:
Driver record, certified
copy with current
record
information ($15)
Driver record, insurance
copy ($15)
A copy of a driver
license application ($15)
A letter verifying a NH
driver license with
original issue date ($15)
A copy of a Driver
Education Certificate
($1)
Certified vehicle/vessel
information for
registration year ______
($15)
A letter verifying a
walking disability
placard ($15)
registered vehicles ($5)
A copy of a bill of sale
($1)
Out-of-state company request for a
information ($20):
Abandoned Vehicle
NH company
information:
Abandoned Vehicle (must
attach a TDMV 71, which can
be found on our website
www.nh.gov/dmv)
Copy of a ticket ($1 per
page): Date: ________
Copy of a suspension
notice ($1 per page):
Date: ___________
Copy of a restoration letter
($1 per page):
Date: ___________
Other (please specify):
_______________________
_______________________
_______________________
_______________________
An accident report ($5
minimum, $1 per page.
You will be notified if cost
exceeds $5). Please
complete the
information to the right
Date of accident:
______/_______/________
Location of accident:
__________________________
Street or Route
___________________________________
City/Town
Title history search for a
vehicle ($20) (this is not a
duplicate title)
documents submitted when
applying for a title ($1 per
page)
Copy of an insurance card
related to an accident
($1).
Who are you? Check ONE of the three boxes below:
__________________________________________________________
First name Middle name Last name
Last known address: ________________________________________
Driver license or ID #: _______________________________________
OR
Plate or Bow #:_____________________________________________
Vehicle or Boat Identification Number (VIN/HIN):
_________________________________________________________
I AM THE RECORD HOLDER OR VEHICLE OWNER of the
above documents I am seeking.
I am representing myself in a court case.
Docket # ___________________ Court: __________________
I AM NOT THE RECORD HOLDER, but the record holder has
approved this request
and has had their signature notarized in
Step 4. The requestor may NOT be the Notary or Justice of the
Peace.
I AM NOT THE RECORD HOLDER but I am a member of a bank
or lienholder, a tow company, a private investigator licensed
by this state, an employer, an insurance company, a public
utility, or a law firm/lawyer, all pursuant to RSA 260:14.
If
checking this box, you must disclose what y
ou intend to use this
information for. You must also submit a Certificate of Authority, or a current
one must be on file at the DMV (see Step 5 for both requirements).
Information of the person filling out this form (the requestor):
*Required information
*Your full name: ________________________________________________________ Your phone number: (________) __________ - ____________________
(Be sure to include a hyphen if applicable.)
*Mailing address: ____________________________________________________________________________________________________________________
Street/PO Box City/Town State Zip
If Applicable:
Company Name: ____________________________________________ NHB#______________________ Prepaid Acct. #: ____________________________
***CONTINUED ON NEXT PAGE SIGNATURE REQUIRED (SEE STEP 7)***
STEP 1
STEP 3
STEP 2
Whose information are you looking for (the record
Full name (include hyphen if applicable):
Notary Public or Justice of the Peace
Acknowledgment
I am the record holder and I authorize my record to be released to the
requester listed in Step 3:
________________________________________ Date: _____/_____/______
Signature of record holder
State of _______, County of ________________,ss. Date: _____/_____/______
The above named _________________________________________ personally
appeared and made oath that the above declaration by him/her is true.
____________________________________ ______/_______/________
Notary Public/Justice of the Peace Commission expires
Affix Seal
This Acknowledgment is
required to be signed by the record
holder ONLY if the record holder is authorizing someone
else to get the requested information.
If the requestor is asking for his/her own information, this
section DOES NOT need to be completed, and you may
proceed to Step 6.
Intended Use of Information:
To be completed
only
if you are a member of a bank or
lienholder, a tow company, a private investigator licensed by this state, an employer, an insurance
company, a public utility, or a law firm/lawyer, all pursuant to RSA 260:14 (see sections below).
Requirements for a
Certificate of Authority (C.O.A.
):
1. Must be on company letterhead.
2. Must list the types of DMV
documents you want.
3. Must state what you intend to do
with the DMV documents named.
4. Must name employees who may
make requests in person/mail for
your company, if any.
5. Must be signed by the
attorney/owner/principal.
6. The NH DMV must have a new
C.O.A. each calendar year. All
expire December 31
st
.
7.
All requests requiring a C.O.A. must
be completed at Concord DMV.
8. A requestor may not sign or
authorize their own C.O.A.
For use in connection with any civil, criminal, administrative or arbitral proceeding. [RSA 260:14, V(a)(2)].
Docket #:________________________ Court: _________________________________________
By a bank or similar institution to verify the accuracy of personal information submitted by the individual to the
bank [RSA 260:14, V(a)(3)].
For providing notice to the owner(s) of a towed or impounded vehicle [RSA 260:14, V(a)(5)]
For providing notice to the owner(s) for storage or a
For use by any private investigative agency or security service licensed by this state for any purpose permitted
pursuant to RSA 260:14, V(a), other than for bulk distribution for surveys, marketing or solicitations pursuant
to RSA 260:14 V(a)(8). Indicate specific reason here: ___________________________ [RSA 260:14, V(a)(6)].
By an employer or its agent or insurer to obtain or verify information relating to a holder of a commercial
drivers license [RSA 260:14, V(a)(7)].
By a public utility to perform its public service obligation provided the individual has given their express consent
[RSA 260:14, V (a)(9)].
For an insurance company or its authorized agent [RSA260:14, IV(a)(2)].
For use by a life insurance company authorized to write life insurance policies, or its authorized agent. In
obtained and that the record will be used solely in connection with claims investigation, rating and underwriting.
[RSA 260:14, V(a)(10)]. Initial here: _______________
IMPORTANT!!! Please read the penalty clause below:
RSA 260:14, IX states as follows: (a) A person is guilty of a misdemeanor if such person knowingly discloses information fro m a department
record to a person known by such person to be an unauthorized person; knowingly makes a false representation to obtain information from a department record; or
knowingly uses such information for any use other than the use authorized by the department. In addition, any professional or business license issued by this state
and held by such person may, upon conviction and at the discretion of the court, be revoked permanently or suspended. Each such unauthorized disclosure,
unauthorized use or false representation shall be considered a separate offense.
Signature (this step is required):
I have read the NH law RSA 260:14 and I understand the limitations placed on the use of information received by the Departmen t of Safety. This
form is signed under penalty of unsworn falsification pursuant to NH law RSA 641:3 and subject to the penalties specified in NH law RSA 260:14, IX.
Signature of Requestor: ____________________________________________________________ Date: _____/_____/________
Submit your request:
Mail: NH DMV, 23 Hazen Drive, Concord NH 03305 (Please indicate ).
In person: You are required to bring photo identification that has not been expired for more than 3 years.
Payment: DMV.
STEP 6
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STEP 5
STEP 8
STEP 4