Form T-77 - Lien Or Security Interest Holder Release To Department Of Revenue Commissioner

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T-77 (Revised 06-2012)
Lien or Security Interest Holder Release to Department of Revenue
Commissioner
___________________________________________________
Vehicle Identification Number
__________________________________ ____________
Current Title Number
State of Issue
__________________________________
_______________________
Vehicle Make
Vehicle Year
__________________________________________________
Name of Owner(s)
________________________________________________________________________
Street
_______________________________________
_______
_____________
City
State
Zip Code
__________________________________________________
__________________________
Name of Security Interest Holder or Lien Holder (as shown on title)
Date Security Interest/Lien Satisfied
________________________________________________________________________
Street
_______________________________________
_______
_____________
City
State
Zip Code
___________________________________
Account Number
________________________________________
__________________________
Date
Signature of Authorized Representative of
Lien or Security Interest Holder
_____________________________________
__________________________
Title of Authorized Representative of Lien
Printed Name of Authorized Representative of
or Security Interest Holder
Lien or Security Interest Holder
__________________________
Telephone Number of Security Interest or
Lien Holder including area code
Important
Alterations or erasures void this form. The DOR reserves the right to verify the validity of this form prior to acceptance. This form must
be typed or legibly printed and 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. *An authorized representative of any branch
office may execute this form on behalf of the parent bank/lending institution.
Mail To:
Georgia Department of Revenue Motor Vehicle Division
P.O. Box 740381, Atlanta, GA 30374-0381

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