Form Vsa 17a - Application For Certificate Of Title And Registration
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2VSA 17A (01/01/2018)
APPLICATION FOR
CERTIFICATE OF TITLE AND REGISTRATION
PURPOSE:
Use this form to apply for a title and/or to register a passenger vehicle, motorcycle, truck, motor home (RV), or trailer.
INSTRUCTIONS:
Complete this form and return to any DMV customer service center (CSC). DMV may request proof of any information provided.
OWNER INFORMATION
APPLICATION TYPE:
Title
Electronic Title Option -- I want DMV to maintain an electronic certificate of
Check one:
YES
NO
Title and Registration (license plates issued)
title on file for this vehicle. (No paper title will be issued)
Check
If this application is for joint ownership, do you wish clear rights of ownership to be transferred to
Vehicle is owned by individual(s).
one:
the surviving owner in the event of the death of either the owner or co-owner?
YES
NO
Vehicle is business owned.
OWNER'S FULL LEGAL NAME (last, first, mi, suffix) OR BUSINESS NAME (if business owned)
TELEPHONE NUMBER
DMV CUSTOMER NUMBER / FEIN / SSN
CO-OWNER'S FULL LEGAL NAME (last, first, mi, suffix)
TELEPHONE NUMBER
DMV CUSTOMER NUMBER / FEIN / SSN
NOTE: Owners (and Lessees if applicable) MUST provide their residence/home/business address where requested, this
RESIDENCE/BUSINESS JURISDICTION
address can not be a P.O. Box. You must complete form ISD-01 if you would like your address(es) updated.
OWNER'S STREET ADDRESS (Apt # if applicable)
CITY
STATE
ZIP CODE
OWNER'S MAILING ADDRESS (if different from above)
CITY
STATE
ZIP CODE
CO-OWNER'S STREET ADDRESS (Apt # if applicable)
CITY
STATE
ZIP CODE
CO-OWNER'S MAILING ADDRESS (if different from above)
CITY
STATE
ZIP CODE
LOCATION WHERE VEHICLE IS PRINCIPALLY GARAGED
Are any of the owners/lessees on active
military duty or service?
CITY
COUNTY
TOWN
OF
YES
NO
IF YOU WOULD LIKE YOUR REGISTRATION RENEWALS SENT TO AN ADDRESS OTHER THAN YOUR RESIDENCE/BUSINESS ADDRESS, ENTER IT BELOW.
REGISTRATION MAILING ADDRESS - OPTIONAL
CITY
STATE
ZIP CODE
VEHICLE INFORMATION
YEAR
MAKE
MODEL
BODY TYPE
VEHICLE IDENTIFICATION NUMBER (VIN)
NUMBER
OF AXLES
EMPTY WEIGHT
GVWR (single vehicle weight - manufacturer)
GROSS WEIGHT (combined truck + attached trailer)
GCWR (combined weight: truck + attached trailer)
IS THIS A
GAS
DIESEL
OTHER FUEL TYPE
PRIMARY
IS THIS A LOW
FUEL
VEHICLE
YES
YES
LOGGING
SPEED VEHICLE?
TYPE
COLOR
ELECTRIC
OTHER
NO
NO
VEHICLE?
IS VEHICLE STATE OR
DIVISION CODE
YES - enter agency code
PREVIOUS TITLE NUMBER
STATE
NO
LOCALITY-OWNED?
LIEN INFORMATION
IS THERE A LIEN ON THIS VEHICLE?
YES - YOU MUST COMPLETE THIS SECTION
NO - SKIP TO THE NEXT SECTION
DATE OF FIRST LIEN (mm/dd/yyyy)
LIENHOLDER NAME
LIENHOLDER CODE
LIENHOLDER MAILING ADDRESS
CITY
STATE
ZIP CODE
For additional liens, complete VSA 66 and attach to this form.
SOURCE OF OWNERSHIP INFORMATION
HOW WAS THIS VEHICLE SOLD TO YOU?
PURCHASE DATE (mm/dd/yyyy)
RENTOR NUMBER
VA DEALER LICENSE NUMBER
(check one)
USED
NEW
DEMONSTRATOR
DEALERS
ONLY
SALES PRICE
PROCESSING FEE
SALES AND USE TAX
VEHICLE PURCHASED FROM
MANUFACTURER REBATE/INCENTIVE
STREET ADDRESS
CITY
STATE
ZIP CODE
LEASE INFORMATION (if applicable)
LESSEE'S FULL LEGAL NAME (last, first, mi, suffix)
TELEPHONE NUMBER
DMV CUSTOMER NUMBER / FEIN / SSN
LESSEE'S RESIDENCE/BUSINESS ADDRESS
CITY
STATE
ZIP CODE
ODOMETER STATEMENT
ODOMETER READING (no tenths)
Federal and state laws require that you state the mileage in connection with the transfer of ownership. Failure to
complete the statement or providing a false statement may result in fines and/or imprisonment.
I certify to the best of my knowledge that: (check one)
The odometer reading above is the ACTUAL MILEAGE of the vehicle.
The odometer reading above is NOT the ACTUAL MILEAGE. (Odometer discrepancy.)
The odometer reading above is IN EXCESS of its mechanical limits.
The model year is at least 10 years or older than the current calendar year and was exempt from odometer disclosure in the prior state of title.
(Applicant must present the out-of-state title showing the exemption)
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