Purpose: Instructions:
Use this form to apply for a supplemental lien, lien transfer, replacement title certificate or substitute title certificate. Submit this form to any DMV customer service center with the appropriate fees. APPLICATION TYPE
SUPPLEMENTAL AND TRANSFER LIENS OR REPLACEMENT AND SUBSTITUTE TITLES
APPLICATION FOR
VSA 66 (07/01/2008)
CHECK ONE: Supplemental Lien: Submit an original title unless the new lienholder is the same as the old lienholder and the lienholder is a participant in the electronic title program. Complete the (1) Owner Information, (2) Vehicle Information, (3) Current Lien Information, (4) Supplemental Lien, and (7) Signatures sections. Transfer of Lien: Submit an original title unless the lienholder is a participant in the electronic title program. Complete the (1) Owner Information, (2) Vehicle Information, (3) Current Lien Information, and (5) Transfer of Lien sections. Replacement Title Certificate: Will be issued only if the original is lost, mutilated or illegible. Once a replacement has been issued, prior title(s) are invalid. Complete the (1) Owner Information and (2) Vehicle Information sections. Complete the (3) Current Lien Information, and (7) Signatures sections, if applicable. Check one: Illegible Lost Mutilated Substitute Title Certificate: Will be issued if there is a change in the information on the title. Complete the (1) Owner Information, (2) Vehicle Information, (6) Substitute Title Certificate Information, and (7) Signatures sections. Complete the (3) Current Lien Information, if applicable.
LOG NUMBER__________________________
1.
OWNER'S FULL LEGAL NAME (last) CO-OWNER'S FULL LEGAL NAME (last) MAILING ADDRESS
(first) (first)
OWNER INFORMATION
(middle) (middle) CITY OR TOWN
(suffix) (suffix)
DMV CUSTOMER NUMBER/EMPLOYER ID NUMBER DMV CUSTOMER NUMBER/EMPLOYER ID NUMBER STATE ZIP CODE
Are any of the vehicle owners on active military duty or service?
2.
VEHICLE IDENTIFICATION NUMBER MAKE MODEL TITLE NUMBER
Yes
No
PLATE TYPE WEIGHT
VEHICLE INFORMATION
PLATE NUMBER BODY TYPE
YEAR
3.
Check one: Printed original title certificate attached LIENHOLDER'S NAME
CURRENT LIEN INFORMATION
Original title certificate is electronic title (no paper title attached) LIENHOLDER'S CODE CITY OR TOWN LIENHOLDER'S CODE CITY OR TOWN LIEN DATE (mm/dd/yyyy) STATE ZIP CODE
TITLE NUMBER _________________________________
FIRST LIEN
LIENHOLDER'S MAILING ADDRESS LIENHOLDER'S NAME
LIEN DATE (mm/dd/yyyy) STATE ZIP CODE
SECOND LIEN
LIENHOLDER'S MAILING ADDRESS
4.
Complete this section only if you wish to transfer a lien. The priority of the security interest will be determined according t o the date of the application filing (46.2-637 Code of Virginia). LIENHOLDER'S NAME MAILING ADDRESS LIENHOLDER'S CODE CITY OR TOWN DATE OF LIEN FILING (mm/dd/yyyy) STATE ZIP CODE
SUPPLEMENTAL LIEN
5.
Complete this section only if you wish to transfer a lien. LIENHOLDER'S NAME MAILING ADDRESS
TRANSFER OF LIEN
LIENHOLDER'S CODE CITY OR TOWN DATE OF LIEN FILING (mm/dd/yyyy) STATE ZIP CODE
LIEN HOLDER NAME NEW LIEN HOLDER NAME
The undersigned lienholder acknowledges this to be a free and voluntary act. BY (Signature) BY (Signature
DATE (mm/dd/yyyy) DATE (mm/dd/yyyy)
6.
Complete this section only when information on the previously issued certificate of title changes. NAME OF DOCUMENT(S) SUBMITTED TO MAKE CHANGE:
SUBSTITUTE TITLE CERTIFICATE
See reverse side for additional information on replacement title certificate
VSA 66 (07/01/2008) Page 2
7.
SIGNATURES
ANY WILLFUL MISINFORMATION GIVEN WITH FRADULENT INTENT MAY BE PUNISHABLE BY LAW. preceding facts are true and valid. Owners must sign when application is made for a supplemental lien and a substitute original title certificate. (Lienholders must sign in the Transfer of Liens section).
OWNER'S SIGNATURE CO-OWNER'S SIGNATURE DATE (mm/dd/yyyy) DATE (mm/dd/yyyy)
I/we hereby make application for a title certificate for the vehicle described herein and for that purpose certify that the
REPLACEMENT TITLE CERTIFICATE DELIVERY PROCEDURES
1. 2. NO OUTSTANDING LIEN: The replacement title certificate will be mailed to the vehicle owner unless a person presenting the owner's application can provide identification and is the owner's authorized representative. OUTSTANDING LIEN: The replacement title certificate will be mailed to the lienholder if a recorded lien has not been satisfied. For evidence of lien satisfaction, the lienholder must indicate on the face of the title that the lien has been satisfied. The lienholder must sign the lien satisfaction. The title should then be forwarded to the owner. An original of a signed lien satisfaction on a lending institution's letterhead or from an individual lienholder is sufficient evidence of lien satisfaction. A lienholder may apply for a replacement title without obtaining the owner(s) signature(s). Lienholder's Signature: ____________________________________________________
INSTRUCTIONS FOR REPLACEMENT TITLE CERTIFICATE ONLY
1. 2. 3. Complete Application Form VSA-66, and pay the fee. If the person returning the completed Form VSA-66, is not the owner or a lienholder, the owner must submit this form with the following written authorization. Authorized person accepting replacement title certificate for owner must present identification.
AUTHORIZATION FOR RECEIPT OF CERTIFICATE OF TITLE
I ____________________________________________________________ ( (Name of Vehicle Owner) to receive the replacement title certificate. ____________________________________________________________ (Owner's Signature) Date: _____/_____/________ MM DD YYYY authorize __________________________________________ (Name of Authorized Representative)
PRIVACY ACT NOTICE
The information, including Social Security Number, is requested in accordance with 46.2-623 (Code of Virginia). Any person who refuses to supply the required information will be denied a Certificate of Title and/or registration. Title and registration records may be disseminated in accordance with 46.2- 208 through 46.2-214, to business, law enforcement, or authorized government entities.
TITLE RELEASED TO
FOR DMV USE ONLY
DATE (mm/dd/yyyy)
TYPE OF IDENTIFICATION PRESENTED
NUMBER OF IDENTIFICATION PRESENTED
