Desired Implementation Date
I
I I I
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)
I
Name of Entity
Individual’s Name
Phone Number Email
☐ SecureTA ☐ Dealertrack ☐ Decision Dynamics, Inc. ☐ PDP Group ☐ VINtek, Inc. ☐ None - Lienholder Self Processing
☐ Other (Name):
☐ Certified
☐
Electronic
Name of Entity
Individual’s Name
Phone Number Email
Texas Department
of
Motor
Vehicles
I
1-
Certified Lienholder Intake
Information
--
This form is only for use for new financial institutions requesting to be a certified lienholder or to participate in the Texas Electronic
Lien and Title (ELT) program. This form must be completed in its entirety. If you are an existing financial institution wishing to
make a
change to your current information, please complete the Certified Lienholder Change Request form.
The name and address provided in the “Financial Institution Information” section will be the name and address populated to the
Texas title record. When submitting this form, you must also complete and submit the Service Level Agreement. The name of the
financial institution and the service provider on this form must match the Service Level Agreement.
IMPORTANT: The department will not create multiple certified or ELT lienholder accounts under the same Federal Employer
Identification Number (FEIN). Only one account per FEIN will be accepted.
Participation Type
Select Applicable Participation Type
Certified lienholders are assigned a certified lienholder ID for use on Texas title applications. Entry of this
number at the time of processing the title application results in the correct name and address appearing on
Texas title record. A certified lienholder receives a paper Texas Certificate of Title.
Electronic certified lienholders are assigned an eTitle lienholder ID for use on Texas title applications. Entry of
this number at the time of processing a title application results in the correct name and address appearing on the
Texas title record. An electronic certified lienholder will be a participant in the Texas ELT system and will not
receive a paper Texas Certificate of Title.
Implementation Information
Note: Actual implementation date will be determined by the
Texas Department of Motor Vehicles.
Financial Institution Information
Service Provider (Entity Submitting/Receiving Processing Files)
Technical Contact Information
Service Level Agreement Contact Inf
ormation
Rev 07/18 Form available online at www.TxDMV.gov Page 1 of 1
