Form T-4 - Notice To The Department Of Revenue Commissioner That The Lien Or Security Interest Described Below Has Been Satisfied

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T-4 (Re v ised 03-2008)
Notice to the Department of Revenue Commissioner That the
Lien or Security Interest Described Below Has Been Satisfied*
If the lien/security interest holder is an ELT (Electronic Lien Title) Participant, a paper lien release
form is unacceptable. The lien/security interest can only be released electronically.
Name(s) of Owner(s)
Vehicle Identification No. (Serial Number)
Street
Current Title Number
State of Issue
Vehicle Make and Year
City, State & Zip Code
Name of Security Interest Holder or Lienholder (as shown on title)
Signature of Authorized Representative of Lien or Security Interest Holder
Printed Name of Authorized Representative of Lien or Security Interest Holder
Street
City, State & Zip Code
Branch Office (When Applicable)
Account Number
Telephone Number of Security Interest or Lien Holder including area code
*An authorized representative of any branch office may execute this form on behalf of the parent
bank/lending institution.
IMPORTANT
Alterations or erasures void this form. The DOR and County Tag Agen t s reserve t he right to
verify the validity of this form prior to acceptance. All fields must be completed including account
number (if applicable), lender's telephone number (including area code) and the printed name of
the authorized representative of the lender.
§40-3-90 (2) of Georgia law provides that a person who, with fraudulent intent, alters or forges an
or an assignment or release of a security interest on a
assignment of a certificate of title
certificate of title or a form the commissioner prescribed shall be guilty of a felony.
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