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(Print) Requester s Home Address: (Print) Requester s Driver License Number: DL State: IT IS UNLAWFUL FOR ANY PERSON TO KNOWINGLY OBTAIN OR DISCLOSE PERSONAL INFORMATION FROM DMV RECORDS EXCEPT AS AUTHORIZED BY STATUTE (PAGE 2). VIOLATORS WILL BE SUBJECT TO A MINIMUM PENALTY OF $2,500.00. PERSONAL INFORMATION INCLUDES AN INDIVIDUAL S DRIVER IDENTIFICATION NUM.

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