Tn Form Ss-4258 - Application For Motor Vehicle Temporary Lien - State Of Tennessee Secretary Of State Page 3

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APPLICATION FOR MOTOR VEHICLE TEMPORARY LIEN
FILING FEE: $10.00
1. SUBMITTER
a. NAME & PHONE NUMBER OF SUBMITTER
b. EMAIL ADDRESS OF SUBMITTER
c. SEND ACKNOWLEDGMENT TO: (Name and Address)
NAME
ADDRESS
CITY
STATE
ZIP
THE ABOVE SPACE IS FOR FILING OFFICE USE ONLY
2. DEBTOR/LESSEE INFORMATION: Provide only one name per Debtor (a or b)
1. DEBTOR
a. INDIVIDUAL’S LAST NAME
FIRST NAME
ADDITIONAL NAME(S) INITIAL(S)
SUFFIX
OR
b. BUSINESS NAME
c. MAILING ADDRESS
CITY
STATE
POSTAL CODE
2. DEBTOR
a. INDIVIDUAL’S LAST NAME
FIRST NAME
ADDITIONAL NAME(S) INITIAL(S)
SUFFIX
OR
b. BUSINESS NAME
c. MAILING ADDRESS
CITY
STATE
POSTAL CODE
3. LIENHOLDER INFORMATION: Provide only one name per LIENHOLDER (a or b)
a. LIENHOLDER NAME
OR
b. INDIVIDUAL’S LAST NAME
FIRST NAME
ADDITIONAL NAME(S) INITIAL(S)
SUFFIX
c. MAILING ADDRESS
CITY
STATE
POSTAL CODE
4a. VEHICLE IDENTIFICATION NUMBER (VIN):
4b. INSTRUMENT CREATING LIEN EXECUTED ON:
/
/
MM
DD
YYYY
5. CERTIFICATION (check both boxes)
I certify that I am aware, pursuant to T.C.A. § 39-17-117, it is a Class E felony for any person to knowingly prepare, sign, or
file any lien or other document with the intent to encumber any real or personal property when such person has no reasonable
basis or any legal cause to place such lien or encumbrance on such real or personal property.
I certify that this Motor Vehicle Temporary Lien application is supported by an underlying debt and that a debt instrument has
been signed by the debtor(s).
SIGNATURE
SIGNATURE DATE
NAME (printed or typed)
SIGNER’S CAPACITY
Note: Pursuant to T.C.A. § 10-7-503 all information on this form is public record.
SS-4258 (Rev. 11/14)
RDA pending

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