The information, including Social Security Number, is requested in accordance with VA Code § 46.2-623. Any person who refuses to supply the required
information will be denied a Certificate of Title and/or registration. Title and registration records may be disseminated in accordance with VA Code §§ 46.2-
208 through 46.2-214, to business, law enforcement, or authorized government entities.
PRIVACY ACT NOTICE
Title Released To
FOR DMV USE ONLY
Date (mm/dd/yyyy)
ID Document Number ID Document Type (specify)
PROOF OF IDENTIFICATION PRESENTED (specify)
5. SUBSTITUTE TITLE CERTIFICATE
Complete this section only when information on the previously issued certificate of title changes. Check applicable box(es):
Legal name change Name change due to the death of the co-owner
Address change and request new title be issued
Add, remove, or change designated beneficiary (multiple owners/no lien - complete VSA 18)
Request a clear title after liens have been satisfied Change the vehicle identification number (VIN) or assign a new VIN
Change the name of the lienholder
Change the name(s) of trustee(s) for a trust
Other (explain)
NAME(S) OF DOCUMENT(S) SUBMITTED TO SUPPORT CHANGE:
I/we hereby make application for a substitute title certificate for the vehicle described herein and for that purpose 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.
DATE (mm/dd/yyyy) OWNER/AUTHORIZED REPRESENTATIVE SIGNATURE
DATE (mm/dd/yyyy) CO-OWNER SIGNATURE
LIENHOLDER SIGNATURE DATE (mm/dd/yyyy)
2. Mutilated Title (attach mutilated title)
I/we certify that the most recent title is mutilated and request a replacement title. I/we hereby make application for a title certificate for the vehicle described
herein and for that purpose 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.
DATE (mm/dd/yyyy) OWNER/AUTHORIZED REPRESENTATIVE SIGNATURE
DATE (mm/dd/yyyy) CO-OWNER SIGNATURE
LIENHOLDER SIGNATURE DATE (mm/dd/yyyy)
3. Illegible Title (attach illegible title)
I/we certify that the most recent title is illegible and request a replacement title. I/we hereby make application for a title certificate for the vehicle described
herein and for that purpose 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.
DATE (mm/dd/yyyy) OWNER/AUTHORIZED REPRESENTATIVE SIGNATURE
DATE (mm/dd/yyyy) CO-OWNER SIGNATURE
LIENHOLDER SIGNATURE DATE (mm/dd/yyyy)
VSA 67 (07/01/2020), Page 2
6. AUTHORIZED REPRESENTATIVE DESIGNATION
The owner has an authorized representative submitting the completed VSA-67. In order for the authorized representative to receive the replacement/
substitute title certificate, the owner must enter the name of the authorized representative and sign below. The authorized representative accepting the
replacement/substitute title certificate for the owner must present proof of identification. If the authorized representative cannot provide proof of
identification, the replacement/substitute title certificate will be mailed to the vehicle owner.
As the vehicle owner, I authorize the individual listed below to receive the replacement title certificate.
AUTHORIZED REPRESENTATIVE NAME VEHICLE OWNER SIGNATURE DATE (mm/dd/yyyy)
