VSA 12 (10/10/2017) AFFIDAVIT IN LIEU OF TITLE CERTIFICATE PURPOSE: Use this form to certify unavailability of a current certificate of title for a motor vehicle, trailer, semitrailer or manufactured home due to loss, unlawful detainment or other legitimate circumstance. INSTRUCTIONS: Complete both sides of this form and other appropriate applications (see reverse for instructions). Submit all forms and applicable fees to DMV at the address above, attention Titling Work Center or present to any DMV Customer Service Center. AFFIDAVIT VERIFICATION SECTION MUST BE COMPLETED ON PAGE 2 OR FORM WILL NOT BE PROCESSED. INSURANCE COMPANIES ONLY: Submit all forms and applicable fees to DMV at the address above, attention Vehicle Branding Work Center. AUTHORIZED AGENT/REPRESENTATIVE NAME (print) (insurance companies only) OWNER TELEPHONE NUMBER( ) CO-OWNER TELEPHONE NUMBER( ) VEHICLE OWNER INFORMATION OWNER NAME (print) (if owner is an insurance company enter company name) CO-OWNER NAME (print) IS OWNER AN INSURANCE COMPANY?If yes, vehicle MUST have been acquired as part of the claims process. Enter authorized agent/representative name in the space provided below. An additional $25.00 fee applies. NO -- See reverse for additional requirements/fees. YES -- OWNER CUSTOMER NUMBER / FEIN VEHICLE INFORMATION MAKE MODEL BODY TYPE COLOR VEHICLE IDENTIFICATION NUMBER (VIN) YEAR SUPPORTING INFORMATION - REQUIRED I/we submit this affidavit in support of my/our application for a certificate of title, salvage certificate or non-repairable certificate for the vehicle described above. The facts regarding my/our acquisition of the vehicle, the reason(s) I/we am/are unable to present a certificate of title for said vehicle, and a description of all efforts made to secure the title are as follows: I/We, the owner(s) listed above, being duly sworn, certify and affirm that all information presented in this form is true and correct, that any documents I/we have presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. I/we make this certification and affirmation under penalty of perjury and I/we understand that knowingly making a false statement or representation on this form is a criminal violation. Further, if the Commissioner of the Virginia DMV issues a certificate of title, salvage certificate or non-repairable certificate pursuant to my/our application and this affidavit, I/we hereby bind myself/ourselves, my/our heirs, assigns and personal representatives to indemnify and save harmless the said Commissioner, and his successors in office, individually and officially, for any loss or damage which may be asserted against him/them or which he/they may sustain as a result thereof. CERTIFICATION AND INDEMNIFICATION DATE (mm/dd/yyyy) CO-OWNER SIGNATURE OWNER OR AUTHORIZED AGENT/REPRESENTATIVE SIGNATURE American LegalNet, Inc. www.FormsWorkFlow.com VSA 12 (10/10/2017) INSTRUCTIONS In order to register a motor vehicle, trailer, semitrailer or manufactured home, or to secure a new title for such a vehicle, the customer must submit a certificate of title. If unable to do so because the title is lost, unlawfully detained by someone who currently holds the title, or if the title is otherwise "not available", the customer may file an affidavit instead. When an insurance company files an affidavit, the affidavit must indicate that the vehicle was acquired as a result of the claims process. Efforts made by the applicant to obtain the certificate of title from the previous owner must also be documented. DMV will review the customer's applications and affidavit submitted along with information concerning the circumstances of the case. If DMV determines that the customer is entitled to registration and or titling, it will register the vehicle and issue a new registration card, license plate(s) and a certificate of title, salvage certificate or non-repairable certificate. Pursuant to Virginia Law, if the current certificate of title for a motor vehicle, trailer, semitrailer or manufactured home is unavailable due to legitimate circumstances, the steps below must be followed: 1.Applicant (owner) must complete and submit form VSA 12, Affidavit in Lieu of Title Certificate.2.Applicant must also complete and submit with this form one of the following:a.Application for Certificate of Title and Registration, VSA 17A -- Applicants use this form to apply for atitle and/or to register a passenger vehicle, truck, motor home (RV), trailer, motorcycle, or for-hire vehicle.b.Application for Certificate of Title - Manufactured Home, VSA 17B -- Applicants use this form to apply for atitle to a manufactured home.c.Salvage Certificate Application, VSA 56 -- Applicants use this form to apply for a salvage certificate.d.Application For Non-Repairable Certificate, VSA 57 -- Applicants use this form to apply for a no-feenon-repairable certificate. Insurance companies use this form to apply for no-fee certificates for non- repairable stolen vehicles or late model vehicles (current year and six preceding years) or any vehicle whose actual value is determined to have been at least $10,000 prior to being damaged.3.Submit the above forms, applicable fees (visit www.dmvnow.com to obtain fees), title and sales and use tax, available original documents evidencing ownership and other supporting affidavits.4.Insurance companies must submit a $25.00 processing fee in addition to the fees associated with the forms listed above. Page 2 AFFIDAVIT VERIFICATION As a sworn law enforcement officer with the VA DMV Law Enforcement Division, I verify that I have taken this sworn affidavit, as authorized by VA Code 247 46.2-217, and, based on the information presented herein and my investigation, the owner(s) presenting this affidavit has/have established his/her/their rightful ownership of the vehicle identified above. DATE (mm/dd/yyyy) DMV LE AGENT NAME (print) DMV LE AGENT SIGNATURE CASE NUMBER REGISTRATION NUMBER NOTARY PUBLIC NAME NOTARY PUBLIC SIGNATUREState/Commonwealth of , city or county of subscribed and sworn to before me on this day of (MONTH) (YEAR) by in the city or county and state aforesaid. NOTARY SEAL/STAMP NOTARIZATION DMV LAW ENFORCEMENT VERIFICATION -- This affidavit must be verified by DMV Law Enforcement or notarized. One of the sections below must be completed. MY COMMISSION EXPIRES (mm/dd/yyyy) American LegalNet, Inc. www.FormsWorkFlow.com