Secretary of State
Beneficiary Claim Form
Secretary of State
Vehicle Services Department
Titles Division
501 S. Second St.
Springfield, IL 62756
217-785-3000
www.cyberdriveillinois.com
This form must be used by the beneficiaries
upon the death of a vehicle owner.
Printed by authority of the State of Illinois. December 2019— 1 — VSD 774.3
This space for use by
Secretary of State.
The individual named as Transfer on Death Beneficiary (TOD), ___________________________________________________,
certifies that the applicant is the TOD Beneficiary of __________________________________________________________,
Name of Deceased
w
ho departed this life on_____________________, and that the deceased person was the lawful owner of the following vehicle:
Date
Year: _________________ Make: __________________ Model: ___________________ Body Type: __________________
Vehicle Identification Number:
nnnnnnnnnnnnnnnnnnn
Current Title Number: ________________________________
n
Check box if you are unable to surrender the current title.
I certify to the best of my knowledge that the odometer reading is: (check only one)
n
Actual mileage.
n
The mileage stated is in excess of its mechanical limits.
n
The odometer reading is not the actual mileage.
n
“WARNING - ODOMETER DISCREPANCY.”
nnnnnn
Odometer reading
I certify that the person shown on the face of the Illinois certificate of title for the above vehicle is the last registered owner
of the vehicle listed above, and that I am listed on the title as successor upon the death of the previous owner.
By my signature, I swear or affirm that this is a true and correct statement. I am aware that the law provides severe penalties
for making false statements under oath.
______________________________ ______________________________ ______________________________
Applicant Signature Applicant Printed Name Date
INSTRUCTIONS
• Attach documentation indicating the vehicle was last titled in Illinois, the vehicle owner and TOD Beneficiary. Verification
can be the title or an Illinois Secretary of State title screen print.
• Attach a copy of certified death certificate for the owner shown on the Illinois title.
• Complete and attach an Application for Vehicle Transaction(s) (VSD 190) along with the $150 title fee and any additional
registration fee(s) if license plates are requested. The beneficiary does not have rights to the deceased owner’s vehicle
registration.
• Attach appropriate tax form and check payable to Illinois Department of Revenue.
• If name of the beneficiary on the decedent’s title is not identical to the name stated on the beneficiary’s paperwork, an
Affidavit of Correction (VSD 393), item number 6, must be completed.
• Submit the completed affidavit and the above documentation to an Illinois Secretary of State facility when applying for an
application for title.
No tenths
