Form Vr-217 - Security Interest Filing Statement
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1Motor Vehicle Administration
VR-217 (03-17)
6601 Ritchie Highway, N.E.
Glen Burnie, Maryland 21062
Security Interest Filing Statement (Filing Fee: $20.00)
The MVA should contact me at: ________________________________________ or _______________________ for any questions regarding this application.
(Email address)
(Phone)
Please print or type all information in black ink.
Notice to secured party:
To perfect your security interest: (Maryland title must accompany two copies of this form)
The security interest as set forth below is perfected on date of creation if this statement, filing fee, and any other information required is delivered to
the Motor Vehicle Administration within ten days from the date this security interest was created. If delivery is made after the tenth day, the date of
perfection is the date received by the Motor Vehicle Administration.
Please Note: If the lien holder is anyone other than a bona fide lending institution (i.e. bank, credit union, finance company or dealer), a lien contract
must accompany this form.
Vehicle to be held as collateral
Year
Make of Vehicle
Body Style
Vehicle Identification Number
Maryland Title Number
Type of Contract
Account Number
(MVA Use Only) Lien Code
Name of Secured Party
Date of Creation
Amount of Lien
$
Street Address of Secured Party
City
County
State
Zip Code
Name of Debtor
Street Address of Debtor
City
County
State
Zip Code
I (we) certify under penalty of perjury that:
A. The lien holder making application has a Maryland lender’s license or sales finance license issued by the Commissioner of Financial, Regulation,
License No. _____________________________________ or
B. The lien holder making application is exempt from obtaining a Maryland lender’s license or sales finance license because the lien holder is a:
Bank
National Banking Association
Trust Company
Savings Bank
Savings and Loan Association
Credit Union
Licensed Dealer (a seller of goods or services not engaged in making loans or acting as a credit service business)
Other person who is not in the business of making loans.
Signature of Lien Holder’s Authorized Agent _________________________________ Date __________________
For MVA Use Only
Printed Name of Authorized Agent _________________________________________ Title __________________
Assignment of Security Interest
Name of Assignee
Street Address of Assignee
City
County
State
Zip Code
Amount of Security Interest Assigned
Date Assigned
Full Amount
Partial Amount
We, the undersigned, certify, under penalty of perjury, that the security interest set forth above has been assigned by
the original secured party named herein to the assignee indicated.
Signature of Original Secured Party
Date
Signature of Assignee
Date
For more information, please call: 410-768-7000 (to speak with a customer agent).
TTY for the hearing impaired: 1-800-492-4575. Visit our website at:
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