New York State Department of Motor Vehicles MV-900.1 (1/11) NOTICE OF LIEN - CHARGE ACCOUNT CUSTOMER www.dmv.ny.gov All information (other than signature) must be typed. Use caution when entering Vehicle, Hull or Manufactured Home ID number. Liens will not be recorded if information is illegible, incorrect or incomplete. Your DMV Charge Account Number: _____________________ VEHICLE/BOAT/MANUFACTURED HOME INFORMATION Identification Number Year This is a: Make Vehicle Body Type/ Hull Boat Trailer Manufactured home Registration/Plate No. of Borrower, if any OWNER INFORMATION Owner’s Last Name First M.I. Owner’s Last Name First M.I. Street Address (including Apt. No.) City State Zip Code Check here if this is a new address NOTE: Lien will be recorded only if the name(s) listed as the owner(s) is EXACTLY the same as the owner(s) recorded, or to be recorded, on the Certificate of Title. If a Certificate of Title has not been issued to this borrower, print the name as it appears on the driver license. OWNER’S STATEMENT: I understand that the lienholder will send this notice to the DEPARTMENT OF MOTOR VEHICLES. If a title was previously issued in my name for this vehicle, boat, trailer or manufactured home, I gave it to the lienholder to be sent to DMV with this notice. I understand that a new Certificate of Title, showing the lienholder’s name, will be mailed to me. OWNER(S): SIGN HERE ± _______________________________± ________________________________ Date _______________ (Must be an original signature. If a POA is used, a copy of the POA must be attached.) (Must be an original signature. If a POA is used, a copy of the POA must be attached.) If signing for a corporation, print your name and title: ______________________________________ ________________________________ (Name) LIEN INFORMATION (Title) Lien Filing Code (assigned by DMV: enter only if a code has been assigned to you or your company) Lienholder’s Name Lienholder’s Name (continued) Street Address State City Zip Code This notice authorizes the Department of Motor Vehicles to disclose (or otherwise make available) information about the lienholder obtained by the department in connection with this record. ±________________________________________________________________________ Date of Security Agreement_________________________ (Lienholder’s Signature—Must be an original signature or a facsimile stamp) Has a NY Certificate of Title been issued to this borrower? YES NO IF YES, ATTACH TITLE. LIENHOLDER: Mail this form and the owner’s title (if issued) to: TITLE BUREAU, NEW YORK STATE DEPARTMENT OF MOTOR VEHICLES PO BOX 2604, ALBANY, NY 12220-0604 You can verify online if a lien was recorded or if a title certificate was issued. Go to the Lien/Title Certificate Status page at the DMV web site: www.dmv.ny.gov/titlestat/default.html MV-900.1 (1/11) DO NOT DETACH THIS RECEIPT YOUR DMV CHARGE ACCOUNT NUMBER: _____________________ PLEASE TYPE LIEN FILING CODE, AND NAME AND ADDRESS OF THE ACCOUNT TO BE CHARGED: Lien Filing Code: Vehicle Identification Number (VIN): Account Name Street Address (including Apt. No.) City or Town State Zip Code American LegalNet, Inc. www.FormsWorkFlow.com