APPLICATION FOR VSA 66 (07/01/2008) SUPPLEMENTAL AND TRANSFER LIENS OR REPLACEMENT AND SUBSTITUTE TITLES 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 1. OWNER INFORMATION OWNER'S FULL LEGAL NAME (last) (first) (middle) (suffix) DMV CUSTOMER NUMBER/EMPLOYER ID NUMBER CO-OWNER'S FULL LEGAL NAME (last) (first) (middle) (suffix) DMV CUSTOMER NUMBER/EMPLOYER ID NUMBER MAILING ADDRESS CITY OR TOWN Are any of the vehicle owners on active military duty or service? 2. Yes ZIP CODE No VEHICLE INFORMATION VEHICLE IDENTIFICATION NUMBER MAKE TITLE NUMBER MODEL PLATE NUMBER YEAR PLATE TYPE BODY TYPE WEIGHT CURRENT LIEN INFORMATION Printed original title certificate attached Original title certificate is electronic title (no paper title attached) LIENHOLDER'S NAME SECOND LIEN LIENHOLDER'S CODE LIEN DATE (mm/dd/yyyy) LIENHOLDER'S MAILING ADDRESS CITY OR TOWN STATE LIENHOLDER'S NAME FIRST LIEN LIENHOLDER'S CODE LIEN DATE (mm/dd/yyyy) LIENHOLDER'S MAILING ADDRESS CITY OR TOWN STATE ZIP CODE ZIP CODE SUPPLEMENTAL LIEN 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 LIENHOLDER'S CODE DATE OF LIEN FILING (mm/dd/yyyy) MAILING ADDRESS CITY OR TOWN STATE ZIP CODE TRANSFER OF LIEN 5. Complete this section only if you wish to transfer a lien. LIENHOLDER'S NAME LIENHOLDER'S CODE DATE OF LIEN FILING (mm/dd/yyyy) MAILING ADDRESS CITY OR TOWN STATE LIEN HOLDER NAME The undersigned lienholder acknowledges this to be a free and voluntary act. BY (Signature) BY (Signature NEW LIEN HOLDER NAME 6. ZIP CODE DATE (mm/dd/yyyy) DATE (mm/dd/yyyy) SUBSTITUTE TITLE CERTIFICATE Complete this section only when information on the previously issued certificate of title changes. NAME OF DOCUMENT(S) SUBMITTED TO MAKE CHANGE: See reverse side for additional information on replacement title certificate American LegalNet, Inc. www.FormsWorkFlow.com TITLE NUMBER _________________________________ 3. Check one: STATE LOG NUMBER__________________________ 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. VSA 66 (07/01/2008) Page 2 7. SIGNATURES ANY WILLFUL MISINFORMATION GIVEN WITH FRADULENT INTENT MAY BE PUNISHABLE BY LAW. I/we hereby make application for a title certificate for the vehicle described herein and for that purpose certify that the 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 DATE (mm/dd/yyyy) CO-OWNER'S SIGNATURE DATE (mm/dd/yyyy) REPLACEMENT TITLE CERTIFICATE DELIVERY PROCEDURES 1. 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. 2. 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. Complete Application Form VSA-66, and pay the fee. 2. 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. 3. Authorized person accepting replacement title certificate for owner must present identification. AUTHORIZATION FOR RECEIPT OF CERTIFICATE OF TITLE I ____________________________________________________________ ( (Name of Vehicle Owner) authorize __________________________________________ (Name of Authorized Representative) to receive the replacement title certificate. ____________________________________________________________ (Owner's Signature) Date: _____/_____/________ MM DD YYYY 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. FOR DMV USE ONLY TITLE RELEASED TO DATE (mm/dd/yyyy) TYPE OF IDENTIFICATION PRESENTED NUMBER OF IDENTIFICATION PRESENTED American LegalNet, Inc. www.FormsWorkFlow.com