Form T-53d - Notice Of Security Interest

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T-53D (Revised 03-2013)
Notice of Security Interest
For County or State Use Only
Filing Fee: $18.00
Receipt Date
This notice of security interest is being submitted for the vehicle described below:
Please read all of the instructions on Page 2 of this form before completing.
Vehicle Information
Vehicle Identification Number
Vehicle Make
Vehicle Year
Body Style
Model Name
Selling Dealership’s Name
Dealership’s Permanent State-Assigned ID#
Dealership’s Street Address
City
State
ZIP Code
Dealership’s County Name
Ownership Information
Owner #1- Full Legal Name
Owner #2- Full Legal Name
Owner’s Street Address
City
State
ZIP Code
Security Interest Information
Name of Security Interest Holder
Security Interest Holder’s Permanent ID#
Security Interest Holder’s Street Address
City
State
ZIP Code
Telephone Number (Including Area Code)
Security Interest’s Creation Date
Authorized Agent’s Printed or Typed Name
Authorized Agent’s Signature

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