VSA 12M (08/10/2017)
DATE (mm/dd/yyyy)
CO-OWNER SIGNATURE OWNER OR AUTHORIZED AGENT/REPRESENTATIVE SIGNATURE
I am (we are) unable to present a certificate of title with respect to the vehicle described because:
NOTARIZATION (must be completed by notary public)
MY COMMISSION EXPIRES (mm/dd/yyyy)
State/Commonwealth of ______________________, city or county of _____________________________
subscribed and sworn to before me on this ____________ day of ________________________________
(MONTH) (YEAR)
by___________________________________________________ in the city or county and state aforesaid.
NOTARY PUBLIC SEAL
REGISTRATION NUMBER
NOTARY PUBLIC NAME NOTARY PUBLIC SIGNATURE
CERTIFICATION
VEHICLE OWNER INFORMATION
OWNER FULL NAME (last, first, middile initial) (print)
CO-OWNER FULL NAME (last, first, middile initial) (print)
OWNER TELEPHONE NUMBER
CO-OWNER TELEPHONE NUMBER
VEHICLE INFORMATION
MAKE
MODEL
BODY TYPE COLOR
VEHICLE IDENTIFICATION NUMBER (VIN)
YEAR
INSTRUCTIONS
In order to register a moped or all terrain vehicle, or to secure a new title for such a vehicle, the customer must submit a certificate of title.
If unable to do so because the title is lost, unlawfully detained by someone who currently holds the title, or if the title is otherwise "not
available", the customer may file this form with DMV instead. Efforts made by the applicant to obtain the certificate of title from the
previous owner must also be documented.
DMV will review the customer's applications and affidavit submitted along with information concerning the circumstances of the case. If
DMV determines that the customer is entitled to registration and or titling, it will register the vehicle and issue a new registration card,
license plate(s) and a certificate of title.
Pursuant to Virginia Law, if the current certificate of title for a moped or all terrain vehicle is unavailable due to legitimate circumstances, to
obtain a registration and or title applicants must complete and submit this form AND form VSA 17A, Application for Certificate of Title and
Registration.
MOPED OR ALL TERRAIN VEHICLE
AFFIDAVIT IN LIEU OF TITLE CERTIFICATE
PURPOSE: Use this form to certify unavailability of a current certificate of title for a moped or all terrain vehicle due to loss, unlawful
detainment or other legitimate circumstance.
INSTRUCTIONS: Complete form and have it notarized. Submit this form with form VSA 17A -- Application for Certificate of Title and
Registration and applicable fees to any DMV customer service center.
The owner(s) listed above certify and affirm that all information presented in this form is true and correct, that any documents I (we) have
presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. I (we) make this
certification and affirmation under penalty of perjury and I (we) understand that knowingly making a false statement or representation on
this form is a criminal violation.
