Print Reset Save Secretary of State VEHICLE TITLE REVOCATION REQUEST Secretary of State Vehicle Services Department 501 S. Second St., Rm. 014 Springfield, IL 62756 Fax (217) 524-1915 www.cyberdriveillinois.com Please print or type This space for use by Secretary of State Vehicle Identification Number Last Name Last Name Address Phone Number(s) Vehicle Make First Name First Name City Vehicle Model Vehicle Year Middle Initial Middle Initial State ZIP Code Driver's License Number(s) o Court Order directing the Secretary of State to specifically revoke the title (signed copy of court order required) o Title Certificate stolen (copy of police report required) Each request must include the correct owner(s) and vehicle information, reason for revocation and signature(s) of the registered/titled owner(s). Failure to include this information will prevent the request from being processed. A leased vehicle record must include the lessor's signature. Revocation of the title does not remove your name from that particular vehicle record. If your vehicle has been recently sold, donated, junked, or has been towed or repossessed, you may not use this form and must complete the Seller's Report of Sale Form. To download, visit www.cyberdriveillinois.com (click Publications, Motorist, Title and Registration). Reason for Title Revocation (check one): Under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certifies that the statements set forth in this instrument are true and correct, except as to matters therein stated to be on information and belief as to such matters the undersigned certifies as foresaid that he verily believes the same to be true. (735 ILCS 5/1-109) __________________________________________________________ Registered Owner's Signature Registered Owner's Signature ______________________________ Date Date __________________________________________________________ ______________________________ Printed by authority of the State of Illinois. December 2014 ­ 1 ­ VSD-850.2 American LegalNet, Inc. www.FormsWorkFlow.com