Fillable form and fees to the Titling Work Center (Virginia Department of Motor Vehicles)

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form and fees to the Titling Work Center (Virginia Department of Motor Vehicles)

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APPLICATION FOR
TRANSFER AND SUPPLEMENTAL LIENS
Are any of the vehicle owners on active military duty or service?
MAILING ADDRESS CITY OR TOWN STATE ZIP CODE
YES NO
OWNER FULL LEGAL NAME (last, first, middle, suffix) DMV CUSTOMER NUMBER / FEIN / SSNTELEPHONE NUMBER
CO-OWNER FULL LEGAL NAME (last, first, middle, suffix) DMV CUSTOMER NUMBER / FEIN / SSNTELEPHONE NUMBER
1. OWNER INFORMATION
3. CURRENT LIEN INFORMATION
FIRST
LIEN
Check One:
Printed original paper title certificate attached Original title certificate is electronic title (no paper title attached)
LIEN DATE (mm/dd/yyyy) LIENHOLDER NAME LIENHOLDER CODE
LIENHOLDER MAILING ADDRESS CITY OR TOWN ZIP CODESTATE
LIEN DATE (mm/dd/yyyy) LIENHOLDER NAME LIENHOLDER CODE
LIENHOLDER MAILING ADDRESS CITY OR TOWN ZIP CODESTATE
SECOND
LIEN
Complete this section only to transfer a lien to a new lienholder.
DATE OF LIEN FILING (mm/dd/yyyy) NEW LIENHOLDER NAME LIENHOLDER CODE
MAILING ADDRESS CITY OR TOWN ZIP CODESTATE
4. TRANSFER OF LIEN
Complete this section to add a lien. The priority of the security interest will be determined according to the date of the application filing
(Virginia Code § 46.2-637).
DATE OF LIEN FILING (mm/dd/yyyy) LIENHOLDER NAME LIENHOLDER CODE
MAILING ADDRESS CITY OR TOWN ZIP CODESTATE
5. SUPPLEMENTAL LIEN
2. VEHICLE INFORMATION
VEHICLE IDENTIFICATION NUMBER (VIN)
YEAR MAKE MODEL BODY TYPE
TITLE NUMBER PLATE NUMBER PLATE TYPE
WEIGHT
APPLICATION TYPE
CHECK ONE:
Transfer of Lien: Submit an original title unless the lienholder is a participant in the electronic title program. Complete sections
(1) Owner Information, (2) Vehicle Information, (3) Current Lien Information, (4) Transfer of Lien, and (6) Certification.
Supplemental Lien: Submit an original title unless the new lienholder is the same as the old lienholder and the lienholder is a
participant in the electronic title program. Complete sections (1) Owner Information, (2) Vehicle Information, (3) Current Lien
Information, (5) Supplemental Lien, and (6) Certification.
VSA 66 (12/20/2016)
Purpose: Use this form to apply for a lien transfer or a supplemental lien.
Instructions: Submit this form to any DMV customer service center with the appropriate fees. You may also mail the
form and fees to the Titling Work Center at the address above.
LOG NUMBER
__________________________
TITLE NUMBER
_________________________________
( )
( )
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.
Owners must sign when application is made for a supplemental lien. Lienholders must sign when transferring a lien.
The information, including Social Security Number, is requested in accordance with §46.2-623 (Virginia Code). 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
Virginia Code §§ 46.2- 208 through 46.2-214, to business, law enforcement, or authorized government entities.
PRIVACY ACT NOTICE
VSA 66 (12/20/2016)
Page 2
6. CERTIFICATION
DATE (mm/dd/yyyy) OWNER SIGNATURE
DATE (mm/dd/yyyy) CO-OWNER SIGNATURE
DATE (mm/dd/yyyy) CURRENT LIENHOLDER NAME (print) CURRENT LIENHOLDER SIGNATURE
DATE (mm/dd/yyyy) NEW LIEN HOLDER NAME (print) NEW LIENHOLDER SIGNATURE
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form and fees to the Titling Work Center (Virginia Department of Motor Vehicles)

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Completed 29 July 2020

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