Application For Certificate Of Title And Registration {VSA 17A}

Are any of the owners/lessees on active military duty or service? YES NO LOCATION WHERE VEHICLE IS PRINCIPALLY GARAGED TOWN OF CITY COUNTY REGISTRATION MAILING ADDRESS - OPTIONAL CITY ZIP CODE STATE 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 CODE STATE OWNER'S MAILING ADDRESS (if different from above) CITY ZIP CODE STATE 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 / SSN CO-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 Title Title and Registration (license plates issued) 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 LIEN INFORMATION IS THERE A LIEN ON THIS VEHICLE? YES - YOU MUST COMPLETE THIS SECTION NO - SKIP TO THE NEXT SECTION DATE OF FIRST LIEN (mm/dd/yyyy) LIENHOLDER NAME LIENHOLDER CODE LIENHOLDER MAILING ADDRESS CITY ZIP CODE STATE For additional liens, complete VSA 66 and attach to this form. APPLICATION FOR CERTIFICATE OF TITLE AND REGISTRATIONPURPOSE: Use this form to apply for a title and/or to register a passenger vehicle, motorcycle, truck, motor home (RV), or trailer. INSTRUCTIONS: Complete this form and return to any DMV customer service center (CSC). DMV may request proof of any information provided. CO-OWNER'S STREET ADDRESS (Apt # if applicable) CITY ZIP CODE STATE CO-OWNER'S MAILING ADDRESS (if different from above) CITY ZIP CODE STATE VEHICLE IDENTIFICATION NUMBER (VIN) YEAR MAKE MODEL BODY TYPE GVWR (single vehicle weight - manufacturer) GCWR (combined weight: truck + attached trailer) VEHICLE COLOR PRIMARY PREVIOUS TITLE NUMBER STATE IS VEHICLE STATE OR LOCALITY-OWNED? NO YES - enter agency code VEHICLE INFORMATION NUMBER OF AXLES GROSS WEIGHT (combined truck + attached trailer) FUEL TYPE GAS ELECTRIC OTHEROTHER FUEL TYPE DIVISION CODE LESSEE'S RESIDENCE/BUSINESS ADDRESS CITY ZIP CODE STATE LESSEE'S FULL LEGAL NAME (last, first, mi, suffix) DMV CUSTOMER NUMBER / FEIN / SSN TELEPHONE NUMBER LEASE INFORMATION (if applicable) SOURCE OF OWNERSHIP INFORMATION HOW WAS THIS VEHICLE SOLD TO YOU? (check one) DEMONSTRATOR USED NEW VEHICLE PURCHASED FROM PURCHASE DATE (mm/dd/yyyy) SALES PRICE PROCESSING FEE SALES AND USE TAX STREET ADDRESS CITY ZIP CODE STATE DEALERS ONLY MANUFACTURER REBATE/INCENTIVE VA DEALER LICENSE NUMBER RENTOR NUMBER IS THIS A LOW SPEED VEHICLE? NO YES IS THIS A LOGGING VEHICLE? NO YES DIESEL I certify to the best of my knowledge that: (check one)(Applicant must present the out-of-state title showing the exemption) Federal and state laws require that you state the mileage in connection with the transfer of ownership. Failure to complete the statement or providing a false statement may result in fines and/or imprisonment. ODOMETER READING (no tenths) The odometer reading above is NOT the ACTUAL MILEAGE. (Odometer discrepancy.) The model year is at least 10 years or older than the current calendar year and was exempt from odometer disclosure in the prior state of title. The odometer reading above is IN EXCESS of its mechanical limits. The odometer reading above is the ACTUAL MILEAGE of the vehicle. ODOMETER STATEMENT VSA 17A (01/01/2018) REGISTRATION PERIOD (check one:) TRANSFER THREE YEARS ($3 discount - not for emissions area) TWO YEARS ($2 discount) ONE YEAR (enter plate number) REGISTRATION TYPE (check one:) FOR HIRE (complete For Hire Information below) RENTAL PRIVATE REGISTRATION INFORMATION NOTE: Virginia offers more than 200 unique plates for our customers. Please visit www.dmvNow.com for a listing of special plates available. Not all plates are available for all vehicle types and some special plates require a certification form. Review our website for additional information. Trailer Permanent - (one time fee) select size: Small size plate (trailer gross weight must be 4,000 lbs or less) Regular size plate Check to indicate how the vehicle being registered will be used (check all that apply). If the vehicle will be used in property carrier operations, and those operations exclusively use passenger cars, motorcycles, autocycles, mopeds, or vehicles with a gross vehicle weight rating (GVWR) of 10,000 pounds or less, then registration for hire is not required. Do you hold a valid intrastate operating authority certificate/permit? If no, and you are a passenger carrier you must also complete the For-Hire Vehicles Registration Request (MCS115). FOR HIRE INFORMATION YES NO Common Carrier - Regular Route Employee Hauler Sight-seeing Carrier Property Carrier * Common Carrier - Irregular Route Contract Passenger Carrier Non-Emergency Medical Transport Household Goods Carrier * Nonprofit/Tax-Exempt Taxicab Exempt Operations - Passengers * Exempt Operations - Property * * You must also complete the For-Hire Vehicles Registration Request (MCS115) PROPERTY CARRIER OPERATIONS PASSENGER CARRIER OPERATIONS I/We 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) DATE (mm/dd/yyyy) APPLICANT NAME (print) SIGNATURE OF APPLICANT SIGNATURE OF CO-APPLICANT CO-APPLICANT NAME (print) CERTIFICATION POWER OF ATTORNEY FOR NON-RESIDENT(S) AND CORPORATION(S) NOT DOMICILED IN VIRGINIA: Pursuant to the provisions of Virginia Code §46.2-601, I/we appoint the Commissioner of the Department of Motor Vehicles of the Commonwealth of Virginia, to be my/our true and legal agent upon whom all legal processes against me/us may be served in any legal proceeding arising from the operation and/or use of any motor vehicle registered in my/our name(s) in the Commonwealth of Virginia. I/we agree that any lawful process or notice to me/us which is served on the Commissioner shall have the same legal effect as if served on me/us within the Commonwealth of Virginia. PRIVACY NOTICE: The information, including Social Security Number, is requested in accordance with Virginia Code §§46.2-623 and 46.2-629. Any person who refuses to supply the required information will be denied a certificate of title and/or registration. By signing this form, you authorize DMV?s exchange of title and registration records with business, law enforcement, or government entities and you authorize DMV?s exchange of title and registration records in accordance with Va. Code §§46.2-208 through 46.2-214 and 18 U.S.C. 2721. NOTICE INSURANCE CERTIFICATIONI/We certify that (check one): This vehicle is insured by a liability policy issued through an insurance company licensed to do business in Virginia and it will remain insured while registered, whether or not it is operated. Penalties are severe for violation of this requirement. Be advised that the amount of liability coverage required is higher for vehicles that are operated for hire. This vehicle is not insured; therefore, I am remitting the applicable uninsured motor vehicle fee. (This fee provides no insurance coverage.) A vehicle must be insured with liability coverage when it is registered, and it must remain insured while registered, whether or not it is operated, or the uninsured motor vehicle fee must be paid. Penalties are severe for violation of