T-17 (Rev. 7-2017)
WEB & MV Manual
Statement of Title Held By Lienholder,
Security Interest Holder or Leasing Company
Vehicle Description
Year Model
Make of Vehicle Vehicle Identification Number (VIN)
Title Number: Name of State Issuing Title:
Owner(s)’ Full Legal Names as Shown on Title:
Name & Address of Title Holder
Title Holder’s Name (Lien or Security Holder or Leasing Company)
Title Holder’s Street Address or P O Box Number
Title Holder’s City, State & Zip
Applicant(s)’ or Lessee(s)’ Signature(s) & Account Number
Owner(s) or Lessee(s) Signature(s)
Account Number:
Acknowledgement
Acknowledgement by County Tax Commissioner or His or Her Designated Employee:
An original valid out-of-state registration certificate or a non-negotiable certificate of title
and a properly completed and signed MV-1 Title Application must accompany
this properly completed and signed form.
Please enter the correct and complete name and address of your leasing company or
lending institution on the title application. Also, if the lessee signs the title application for
the leasing company, a power of attorney must be submitted authorizing the lessee to
sign for the leasing company.
This is to certify that the titleholder, whose name and address is shown below,
is holding the title for the following described vehicle for payment of a lien,
security interest or as required by a lease agreement:
