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Application For Certificate Of Title And Registration VSA 17A - Virginia
| Application For Certificate Of Title And Registration Form. This is a Virginia form and can be used in Department Of Motor Vehicles Statewide . |
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APPLICATION FOR VSA 17A (07/01/2012) CERTIFICATE OF TITLE AND REGISTRATION PURPOSE: INSTRUCTIONS: Use this form to apply for a title and/or to register a passenger vehicle, motorcycle, truck, motor home (RV), or trailer. Complete this form and return to any DMV customer service center (CSC). DMV may request proof of any information provided. ACQUISITION TYPE (check all that apply) Original Title is Electronic (No paper attached) Court Order Replevin Seizure Replica Reconstructed Specially Constructed Converted Electric Abandoned Vehicle (Complete VSA 40) Mechanic's Lien/Storage Lien (Complete VSA 41) Repossession (Vehicle must be in your possession) Leased Rental LOG NUMBER ____________________________________ OWNER INFORMATION Title Electronic Title Option -- I want DMV to maintain an electronic certificate of Check one: YES NO title on file for this vehicle. (No paper title will be issued) Title and Registration (license plates issued) Check If this application is for joint ownership, do you wish clear rights of ownership to be transferred to Vehicle is owned by individual(s). one: the surviving owner in the event of the death of either the owner or co-owner? YES NO Vehicle is business owned. APPLICATION TYPE: OWNER'S FULL LEGAL NAME (last, first, mi, suffix) OR BUSINESS NAME (if business owned) CO-OWNER'S FULL LEGAL NAME (last, first, mi, suffix) TELEPHONE NUMBER TELEPHONE NUMBER DMV CUSTOMER NUMBER / FEIN / SSN DMV CUSTOMER NUMBER / FEIN / SSN RESIDENCE/BUSINESS JURISDICTION STATE STATE ZIP CODE ZIP CODE 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. OWNER'S RESIDENCE/HOME/BUSINESS ADDRESS (Apt # if applicable) CITY CO-OWNER'S RESIDENCE/HOME/BUSINESS ADDRESS (Apt # if applicable) CITY ADDITIONAL INFORMATION LOCATION WHERE VEHICLE IS PRINCIPALLY GARAGED CITY COUNTY TOWN OF REGISTRATION MAILING ADDRESS - OPTIONAL CITY Are any of the owners/lessees on active military duty or service? YES NO STATE ZIP CODE IF YOU WOULD LIKE YOUR REGISTRATION RENEWALS SENT TO AN ADDRESS OTHER THAN YOUR RESIDENCE/BUSINESS ADDRESS, ENTER IT BELOW. LEASE INFORMATION (if applicable) LESSEE'S FULL LEGAL NAME (last, first, mi, suffix) LESSEE'S RESIDENCE/BUSINESS ADDRESS CITY TELEPHONE NUMBER DMV CUSTOMER NUMBER / FEIN / SSN STATE ZIP CODE LIEN INFORMATION IS THERE A LIEN ON THIS VEHICLE? DATE OF FIRST LIEN (mm/dd/yyyy) LIENHOLDER MAILING ADDRESS DATE OF SECOND LIEN (mm/dd/yyyy) LIENHOLDER MAILING ADDRESS LIENHOLDER NAME CITY YES - YOU MUST COMPLETE THIS SECTION LIENHOLDER NAME CITY NO - SKIP TO THE NEXT SECTION LIENHOLDER CODE TITLE NUMBER ____________________________________ STATE ZIP CODE LIENHOLDER CODE STATE ZIP CODE VEHICLE INFORMATION YEAR MAKE GROSS WEIGHT VEHICLE COLOR MODEL GROSS VEHICLE WEIGHT RATING (GVWR) PRIMARY SECONDARY BODY TYPE VEHICLE IDENTIFICATION NUMBER (VIN) NUMBER OF AXLES EMPTY WEIGHT FUEL TYPE GROSS COMBINATION WEIGHT RATING (GCWR) PREVIOUS TITLE NUMBER IS VEHICLE POWERED BY AN ALL ELECTRIC ENGINE? YES NO STATE IS THIS A LOW SPEED VEHICLE? YES YES NO IS VEHICLE STATE OR LOCALITY-OWNED? YES - enter agency code NO AGENCY CODE IS THIS A LOGGING NO VEHICLE? NAME OF UNIT HAVING OPERATIONAL CONTROL PERSONAL PROPERTY TAX RELIEF ELIGIBILITY (Passenger vehicles only) 1. Answer the questions below to determine if your vehicle qualifies for car tax relief. YES NO a. Is more than 50% of the vehicle's annual mileage used as a business expense for federal income tax purposes OR reimbursed by an employer? b. Is more than 50% of the depreciation associated with the vehicle deducted as a business expense for federal income tax purposes? c. Is the cost of the vehicle expensed pursuant to Section 179 of the Internal Revenue Service Code? d. If the vehicle is leased by an individual, does the leasing company pay the tax without reimbursement from the individual? 2. If you answered YES to ANY of the above questions, check Business Use. Your vehicle is considered by State law to have a business use and does BUSINESS USE NOT qualify for Personal Property Tax Relief. 3. If you answered NO to ALL of the above questions, check Personal Use and answer the question below. PERSONAL USE -- Is this vehicle held in a private trust for non-business purposes by an individual beneficiary? YES NO American LegalNet, Inc. www.FormsWorkFlow.com VSA 17A (07/01/2012) Page 2 SOURCE OF OWNERSHIP INFORMATION HOW WAS THIS VEHICLE SOLD TO YOU? VA DEALER LICENSE NUMBER (check one) USED NEW DEMONSTRATOR VEHICLE PURCHASED FROM STREET ADDRESS CITY RENTOR NUMBER SALES PRICE PURCHASE DATE (mm/dd/yyyy) PROCESSING FEE SALES AND USE TAX STATE ZIP CODE ODOMETER STATEMENT ODOMETER READING (no tenths) 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. I certify to the best of my knowledge that: (check one) The odometer reading above is the ACTUAL MILEAGE of the vehicle. The odometer reading above is IN EXCESS of its mechanical limits. 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. (Applicant must present the out-of-state title showing the exemption) REGISTRATION INFORMATION REGISTRATION PERIOD (check one:) REGISTRATION TYPE (check one:) ONE YEAR PRIVATE TWO YEARS ($2 discount applies) RENTAL FOR HIRE (complete For Hire Information below) FOR HIRE INFORMATION Check to indicate how the vehicle being registered will be used. (check all that apply) PASSENGER CARRIER OPERATIONS PROPERTY CARRIER OPERATIONS Common Carrier - Regular Route Employee Hauler Sight-seeing Carrier Common Carrier - Irregular Route Contract Passenger Carrier Non-Emergency Medical Transport Nonprofit/Tax-Exempt Taxicab Exempt Operations - Passengers * * You must also complete the For-Hire Vehicles Registration Request (MCS115) 1. Do you hold a valid intrastate operating authority certificate/permit? YES NO Bulk Property Carrier Property Carrier Household Goods Carrier Exempt Operations - Property If no, and you are a passenger carrier you must also complete the for-hire vehicles registration request (MCS115). TYPE OF PLATE REQUESTED Select requested plate type and ente
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