Pennsylvania Affidavit Requirements

Background

To facilitate monitoring enrollments or the purchase of on-demand MVRs, PennDOT mandates that customers obtain an Access Code from the state. The Access Codes provided by the state of PA are an integral process to acquiring records. They have more stringent standards, and the consequences for failure to comply are far more serious.

• PA will assign each Operating Authority (employer) a single Access Code. In order to provision a customer’s account, SambaSafety only needs one Access Code for the customer.
• If a customer has Driver’s licensed in Pennsylvania in which they would like to enroll in MVR Monitoring, the customer must have the Pennsylvania Affidavit form completed.
• Failure to complete the Pennsylvania Affidavit process will result in an error response for any attempt to enroll Drivers licensed in Pennsylvania.

How to complete the Pennsylvania affidavit

• The Pennsylvania Affidavit can be found by clicking this link: Pennsylvania Affidavit.
• The affidavit must be completed and signed by a member of your agency or firm who has the authority to certify the agency or firm’s compliance.
• Each line item on the form must be completed in its entirety to avoid delays in processing the affidavit. If the requested information does not apply to your business, insert N/A (not-applicable) on that line.
• The person responsible for completing the affidavit must initial each of the nine (9) declaration statements, then sign and date the form in the presence of a Notary.
• The signature provided must be a wet signature. PennDOT will not accept e-signatures.
• Once you have completed the affidavit, it must be returned to SambaSafety in order for the state to process it.
• You are required to complete, notarize, and file a new Affidavit of Intended Use whenever information about your company changes. (name, address, ownership, telephone, website, etc.)

Once I complete the affidavit, where do i send the form?

Please send completed forms to your assigned Implementation contact. If this process is completed after Implementation, please work with the Encompass Support. Please note, it can take 6-8 weeks to establish the Access Code with PennDOT.