VSA 17B (01/01/2018)
APPLICATION FOR CERTIFICATE
OF TITLE - MANUFACTURED HOME
Purpose: Use this form to title a manufactured home. Do not use for self-propelled vehicles or travel trailers.
Instructions: Complete this form and return to any DMV customer service center. DMV may request proof of any
information provided.
Is there a lien on this vehicle? If yes, you must complete this section.
LIEN INFORMATION
FIRST LIEN DATE (mm/dd/yyyy)
Yes No
LIENHOLDER NAME LIENHOLDER CODE
LIENHOLDER MAILING ADDRESS CITY/TOWN STATE ZIP CODE
SECOND LIEN DATE (mm/dd/yyyy) LIENHOLDER NAME LIENHOLDER CODE
LIENHOLDER MAILING ADDRESS CITY/TOWN STATE ZIP CODE
SOURCE OF OWNERSHIP INFORMATION
RENTOR NUMBER
VEHICLE PURCHASED FROMSALES PRICE PROCESSING FEE SALES AND USE TAX
PURCHASE DATE (mm/dd/yyyy)
HOW WAS THIS VEHICLE SOLD TO YOU?
(check one)
USED NEW
STREET ADDRESS
CITY
ZIP CODE
STATE
DEALERS
ONLY
MANUFACTURER REBATE/INCENTIVE
VA DEALER LICENSE NUMBER
Are any of the owners/lessees on active
military duty or service?
YES NO
LOCATION WHERE VEHICLE IS PRINCIPALLY GARAGED
TOWN OFCITY COUNTY
REGISTRATION MAILING ADDRESS - OPTIONAL CITY ZIP CODESTATE
IF YOU WOULD LIKE YOUR REGISTRATION RENEWALS SENT TO AN ADDRESS OTHER THAN YOUR RESIDENCE/BUSINESS ADDRESS, ENTER IT BELOW.
OWNER'S STREET ADDRESS (Apt # if applicable) CITY ZIP CODESTATE
OWNER'S MAILING ADDRESS (if different from above)
CITY
ZIP CODESTATE
NOTE: Owners (and Lessees if applicable) MUST provide their residence/home/business address where requested,
this address can not be a P.O. Box. You must complete form ISD-01 if you would like your address(es) updated.
RESIDENCE/BUSINESS JURISDICTION
DMV CUSTOMER NUMBER / FEIN / SSNCO-OWNER'S FULL LEGAL NAME (last, first, mi, suffix) TELEPHONE NUMBER
If this application is for joint ownership, do you wish clear rights of
ownership to be transferred to the surviving owner in the event of
the death of either the owner or co-owner?
YES NO
OWNER'S FULL LEGAL NAME (last, first, mi, suffix) OR BUSINESS NAME (if business owned) DMV CUSTOMER NUMBER / FEIN / SSN
Check
one:
Vehicle is owned by individual(s).
Vehicle is business owned.
TELEPHONE NUMBER
OWNER INFORMATION
Electronic Title Option -- I want DMV to maintain an electronic certificate of title on file for this vehicle. (No paper title will be issued)
YES NO
CO-OWNER'S STREET ADDRESS (Apt # if applicable)
CITY
ZIP CODESTATE
CO-OWNER'S MAILING ADDRESS (if different from above)
CITY
ZIP CODESTATE
LOG NUMBER ____________________________________ TITLE NUMBER ____________________________________
