Secretary Of State-Beneficiary Claim Form

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Secretary of State
This space for use by
Secretary of State.
eneficiary Claim Form
Secretary of State
Vehicle Services Department
Titles Division
This form must be used by the beneficiaries
501 S. Second St.
upon the death of a vehicle owner.
Springfield, IL 62756
217-785-3000
The individual named as Transfer on Death Beneficiary, ________________________________________________________,
certifies that the applicant is the TOD Beneficiary of __________________________________________________________,
Name of Deceased
who departed this life on_____________________, and that the deceased person was the lawful owner of the following vehicle:
Date
Year: _________________ Make: __________________ Model: ___________________ Body Type: __________________
Vehicle Identification Number:
nnnnnnnnnnnnnnnnnnn
n
Current Title Number: ________________________________
Check box if you are unable to surrender the current title.
I certify to the best of my knowledge that the odometer reading is: (check only one)
n
Actual mileage.
n
The mileage stated is in excess of its mechanical limits.
n
The odometer reading is not the actual mileage.
nnnnnn
n
“WARNING - ODOMETER DISCREPANCY”
No tenths
Odometer reading
I certify that the person shown on the face of the Illinois certificate of title for the above vehicle is the last registered owner
of the vehicle listed above, and that I am listed on the title as successor upon the death of the previous owner.
By my signature, I swear or affirm that this is a true and correct statement. I am aware that the law provides severe penalties
for making false statements under oath.
______________________________
______________________________
______________________________
Applicant Signature
Applicant Printed Name
Date
INSTRU TIONS
• Attach documentation indicating the vehicle was last titled in Illinois, the vehicle owner and TOD beneficiary. Verification
can be the title or an Illinois Secretary of State title screen print.
• Attach a copy of certified death certificate for the owner shown on the Illinois Title.
• Complete and attach an Application for Vehicle Transaction(s) (VSD 190) along with the $95 title fee and any additional
registration fee(s) if license plates are requested. The beneficiary does not have rights to the deceased owner’s vehicle
registration.
• Attach appropriate tax form and check payable to Illinois Department of Revenue.
• If name of the beneficiary on the decedent’s title is not identical to the name stated on the beneficiary’s paperwork, an
Affidavit of Correction (VSD 393), item number 6, must be completed.
• Submit the completed affidavit and the above documentation to an Illinois Secretary of State facility when applying for an
application for title.
Printed by authority of the State of Illinois. May 2013 — 1 — VSD 774.2

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