Tn Form Ss-4258 - Application For Motor Vehicle Temporary Lien - State Of Tennessee Secretary Of State Page 2
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31. SUBMITTER - This information is required. To assist the filing office in communicating with the filer to resolve
any issues, enter:
1a. contact name and phone number;
1b. email address for contact person; and
1c. name and complete address to whom the filing acknowledgment should be sent.
2. DEBTOR/LESSEE INFORMATION: Provide the name and address for each Debtor.
2a. INDIVIDUAL NAME - If the Debtor is an individual person, provide the individual’s name in line (a). Enter
individual Debtor’s last name in INDIVIDUAL’S LAST NAME box, first given name in FIRST NAME box,
and all additional given names or initials in ADDITIONAL NAME(S) INITIAL(S) box.
2b. BUSINESS NAME - If the Debtor is a business entity, provide the business entity’s legal name in line (b).
Only one name, in either line (a) or (b), is allowed for each Debtor.
2c. MAILING ADDRESS - A complete address is always required for each Debtor named. Our system will
standardize the address in United States Postal Service (USPS) format.
If there is a second Debtor, provide the second Debtor’s name in the second Debtor field, which is
immediately below the first Debtor field and is labeled “2. DEBTOR”. If you have more than two
Debtors, you will need to file and pay for additional applications for every two Debtors. Each paper
application may only contain two Debtors.
3. LIENHOLDER INFORMATION - Provide the name and address for the First Lienholder
3a. LIENHOLDER BUSINESS NAME - If the First Lienholder is a business entity, provide the business
entity’s legal name in line (a).
3b. LIENHOLDER INDIVIDUAL NAME - If the First Lienholder is an individual person, provide the individual’s
name in line (b). Enter individual lienholder’s last name in INDIVIDUAL’S LAST NAME box, first given
name in FIRST NAME box, and all additional given names or initials in ADDITIONAL NAME(S)
INITIAL(S) box.
3c. LIENHOLDER MAILING ADDRESS - Provide the complete address for the First Lienholder. Our system
will standardize the address in United States Postal Service (USPS) format.
4a. VEHICLE IDENTIFICATION NUMBER (VIN) - enter the VIN number.
4b. INSTRUMENT CREATING LIEN EXECUTIED ON: - enter the date the underlying debt instrument evidencing
the debt was signed by the parties. The format should be MM/DD/YYYY.
5. CERTIFICATION – Read and place a check in both boxes if you agree.
Sign the Application, write out your name without cursive (print or type), and list your capacity to sign on behalf of
the submitter. Also provide the date that you signed this Application.
FILING FEE
•
The filing fee is $10.00 per Application.
•
Make check, cashier’s check or money order payable to the Tennessee Secretary of State. Cash is only
accepted for walk-in filings. Filings submitted without the proper filing fee will be rejected. Checks, cashier’s
checks or money orders made out to any payee other than the Tennessee Secretary of State will not be
accepted and will result in the rejection of the document.
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