☐ Other (explain)
Desired Implementation Date
I I I
☐ Technical Contact Information ☐ Service Level Agreement Contact Information
Name (max. 30 characters) Federal Employer Identification Number (FEIN)
Address Line 1 (max. 30 characters)
Address Line 2 ( max. 30 characters)
City (max. 19 characters) State (2 characters) Country (max. 4 characters) Postal Code (9 characters)
Name of Entity
Phone Number Email
☐ SecureTA ☐ Dealertrack ☐ Decision Dynamics, Inc. ☐ PDP Group ☐ VINtek, Inc. ☐ None - Lienholder Self Processing
☐ Other (Name):
Certified Lienholder Change Request
This form is only for use by existing financial institutions who are certified lienholders or participating in the Texas Electronic Lien
and Title (ELT) program. If you are a new financial institution wishing to be a certified lienholder or to participate in the ELT
program, please complete the Certified Lienholder Intake form.
The name and address provided in the “Financial Institution Information” section will be the name and address populated to the
Texas title record.
Change Request Type
Select Applicable Change Request Type
The financial institution’s name has changed. This will be effective on records once implemented. Some
TxDMV systems will continue to reflect the name as it appeared at the time the title record was created.
REQUIRED: Attach an explanation on the financial institution’s letterhead, signed by an authorized agent of
the financial institution, explaining the reason for the name change (e.g. rebranding, merger, acquisition).
nancial institution’s address has changed. This will be effective on records once implemented. Some
TxDMV systems may continue to reflect the address as it appeared at the time the title record was created.
The financial institution is changing from one service provider to another. The financial institution and service
providers are responsible for the transfer of records within the service providers’ systems. NOTE: A new
Service Level Agreement must be completed between the new service provider and the financial institution.
technical contact or the Service
Level Agreement contact information has changed. Complete the
“Change Contact Information” section below to reflect the new contacts.
The financial institution wishes to withdraw from the certified lienholder or ELT program. Prior to the TxDMV
processing this request for an ELT lienholder, the ELT lienholder must release all existing electronic titles or
request those electronic titles be converted to paper through their current service provider.
Note: Actual implementation date will be determined by the
Texas Department of Motor Vehicles.
Financial Institution Information – All information with the change request reflected
Service Provider (Entity Submitting/Receiving Processing Files)
Change Contact Information – if applicable
Rev 07/18 Form available online at www.TxDMV.gov Page 1 of 1