PSB-4 Form – The PSB-4 Form, officially known as the Private Service Bureau Employee Roster, is a mandatory New York State Department of Motor Vehicles (NY DMV) document. Private Service Bureaus (PSBs) use it to list owners, partners, corporate officers, managers, agents, and all employees (paid or unpaid) who assist customers with driver licenses, vehicle registrations, titles, and other DMV transactions.
This form ensures the DMV maintains an up-to-date record of individuals authorized to represent PSBs. It is revised as PSB-4 (8/24) and remains the current official version.
Purpose of the NY DMV PSB-4 Form
The PSB-4 Form helps the NY DMV verify the background and eligibility of everyone associated with a licensed Private Service Bureau. PSBs must submit it:
- With the initial application for a PSB license (Form MV-372) or branch office.
- Any time a new employee, runner, or agent is added to the business.
Submitting the roster maintains compliance with Part 77 of the Commissioner’s Rules and Regulations for Private Service Bureaus. It prevents unauthorized individuals from handling DMV paperwork and protects customers.
Who Must Complete and Submit the PSB-4 Employee Roster Form?
Every person connected to a PSB must complete a separate PSB-4 Form, including:
- Business owners and partners
- Corporate officers and managers
- Agents and runners (paid or unpaid)
- All new employees with direct customer or DMV contact
Note: All listed individuals who have in-person contact with customers or DMV documents must hold a valid New York State driver license or non-driver ID card.
Step-by-Step Guide: How to Fill Out the PSB-4 Form?
Filling out the PSB-4 Form is straightforward. Follow these steps exactly:
- Section 1 – Employee Information
Enter full name, driver license number, last 4 digits of Social Security number, and date hired. - Section 3 – Background Questions
Answer five yes/no questions about prior DMV license denials, affiliations with other PSBs, professional misconduct, criminal convictions, or pending charges. Provide details in the “Remarks” section if “Yes” is answered to any question. - PSB Business Details
Include the PSB name, license number, today’s date, full mailing address, telephone, and fax number. - Signatures
Both the PSB owner (or authorized representative) and the employee must sign and date the form. Include the owner’s printed name and title.
Important: Print or type clearly. Incomplete or illegible forms will be rejected.
Required Documents to Submit with the PSB-4 Form
- A photocopy of the employee’s valid New York State driver license or non-driver ID card (front and back).
- The fully completed and signed PSB-4 Form.
- Any supporting explanations for “Yes” answers in the background section.
Official Download: PSB-4 Private Service Bureau Employee Roster PDF
You can download the latest official PSB-4 Form directly from the NY DMV website here:
https://dmv.ny.gov/forms/psb4.pdf
The form is free, fillable, and printable. Always use the most recent version from the official DMV site to avoid processing delays.
Where and How to Submit the Completed PSB-4 Form?
Mail or deliver the completed PSB-4 Form and supporting documents to:
NYS Department of Motor Vehicles
Partnering Programs, PSB Unit
6 Empire State Plaza, Room 322
Albany, NY 12228
Submit the form immediately when adding any new employee. Failure to do so can result in suspension or revocation of your PSB license.
Key Requirements, Notes, and Penalties for the PSB-4 Form
- The owner and employee must affirm that all information is true and accurate.
- Knowingly making a false statement is a criminal offense under New York Penal Law § 210.45 and Vehicle and Traffic Law § 392.
- Material false statements or concealment of facts can lead to license suspension or revocation under Vehicle and Traffic Law § 394(5).
- Former DMV employees should review Public Officers Law restrictions before submitting.
Frequently Asked Questions (FAQs) About the PSB-4 Form
Q: How often do I need to submit the PSB-4 Form?
A: Once with your initial PSB license application and every time you add a new employee, runner, or agent.
Q: Can I submit the form electronically?
A: No. The current process requires mailing or physical delivery to the PSB Unit in Albany.
Q: What if an employee leaves the PSB?
A: You do not need to submit a new PSB-4 for departing employees, but you must keep your internal records updated.
Q: Is the PSB-4 Form required for owners only?
A: No. Every owner, partner, officer, manager, agent, and employee must complete and sign their own PSB-4.
Q: Where can I find more information about Private Service Bureaus?
A: Visit the official NY DMV Private Service Bureau Licenses page for full licensing requirements and related forms.
Stay Compliant with the PSB-4 Form
Proper use of the PSB-4 Private Service Bureau Employee Roster Form keeps your NY DMV license in good standing and ensures smooth operations. Always download the official PDF from the trusted source and submit updates promptly.
For the latest instructions, refer directly to the New York DMV website at https://dmv.ny.gov/business/private-service-bureau-licenses. Keep your PSB records current and protect your business.