Form Ss-4258 - Motor Vehicle Temporary Lien Program

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State of Tennessee
Department of State
Motor Vehicle Temporary Lien Program
Return Acknowledgment Notice To:
Control Number:
Name
_______________________________________
Address
_______________________________________
_______________________________________
______________________, _____ _______
City
State
Zip Code
(Filing Office Use Only)
Motor Vehicle Identification Number:
Lienholder Information:
__________________________________
Business ____________________________________
or
Name
_____________ _______ ______________
First
Middle
Last
Instrument Creating Lien Executed On:
Address
____________________________________
____________________________________
__ __/ __ __/ __ __ __ __
___________________, _____ ________
M M
D D
YEAR
City
State
Zip Code
Debtors / Lessee Information
Payment Method
Business
__________________________________
or
Check
Number ___________
Name
______________ _______ ___________
First
Middle
Last
Address
__________________________________
Voucher
Number ___________
__________________________________
_________________, ______ ________
City
State
Zip Code
In order to record a motor vehicle temporary lien, this form MUST be completed (typed or printed in ink) in its
entirety and returned with a notarized copy of the instrument creating the lien and the required fee of $10.00 (ten
dollars) to:
Tennessee Department of State
Motor Vehicle Temporary Lien Program
312 Eighth Avenue North
6th Floor, William R. Snodgrass Tower
Nashville, TN 37243-0306
(615) 741-0529
SS-4258
RDA Pending

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