Form Ta-Vt-19 5m - Application For Title Changes Including Filing Notice Of Security Interest

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State of Vermont

[Phone]

802-828-2000

DEPARTMENT OF MOTOR VEHICLES

802-828-2098

[Fax]

120 State Street

[Toll Free]

888-99-VERMONT

Montpelier, VT 05603-0001

[TTD]

711

APPLICATION FOR TITLE CHANGES INCLUDING FILING NOTICE OF SECURITY INTEREST

(To Record a Lien)

Complete the following required information. If any information is missing, the form will be returned to you for completion.

MAKE

YEAR

BODY/HULL TYPE

VESSEL LENGTH

VEHICLE/VESSEL IDENTIFICATION NUMBER

Ft.

In.

OWNER’S NAME

OWNER’S MAILING ADDRESS

OWNER’S DATE OF BIRTH

OWNER’S SOCIAL SECURITY NO.*

VT LICENSE/ID #:

CO-OWNER’S NAME

CO-OWNER’S MAILING ADDRESS

CO-OWNER’S DATE OF BIRTH

CO-OWNER’S SOCIAL SECURITY NO.*

VT LICENSE/ID #:

 If you are adding or deleting an owner, check the appropriate box:

 Add

 Delete

If you are adding an owner, write the co-owner’s date of birth and social security number in the fields above. Adding or deleting a name on a

title WILL require the same change on the registration. Please check your registration certificate before submitting this form. Refer to fee

schedule (on back of form) for charges incurred due to your requested changes. Both signatures are required.



If the address on the application is different from the address on Department records, this application will be considered a notice of address

change and your address will be changed on all of your DMV records.

IF THERE IS MORE THAN ONE OWNER, YOU MUST INDICATE THE RIGHTS OF SURVIVORSHIP. CHECK ONE BELOW:



TENANTS BY THE ENTIRETY

JOINT TENANTS

TENANTS IN COMMON

PARTNERS

TRANSFER ON DEATH

Implies Rights of

No Rights of Survivorship

(Business) Implies

Implies Rights of

Husband & Wife

Survivorship

Rights of Survivorship

Survivorship

Parties to a Civil Union

AN ODOMETER, HUBOMETER OR CLOCK METER READING IS REQUIRED FOR VEHICLES

The reading must be a whole number indicated as miles, kilometers or hours. If vehicle is not equipped with one of these devices, submit a signed statement

identifying the vehicle by make, year, and VIN indicating the vehicle is not equipped with one of these devices.

EXPIRATION DATE

METER READING (INDICATE ACTUAL NUMERIC READING)

PLATE NUMBER

(MM/YY)

 Miles  Kilometers  Hours



The odometer reading is the actual mileage

CHECK

The odometer reading reflects the amount of mileage in excess



of its mechanical limits

ONE:

The odometer reading is not the actual mileage

THE UNDERSIGNED, being the lawful owner(s) of the vehicle named herein, hereby gives notice of the creation of a security interest in said

vehicle as follows:

LIENHOLDER'S NAME

LIENHOLDER’S MAILING ADDRESS

DATE OF LIEN:

AND HEREBY REQUESTS that this information be recorded upon the Certificate of Title to be issued for this vehicle/vessel. I understand that

said Certificate of Title will be mailed to the lienholder in approximately 4 weeks. THIS DECLARATION IS MADE UNDER PENALTIES OF 23

VSA §§ 202, 2082, 2083, 2093 and 3829 (a) 4.

SIGNATURE OF OWNER

DATE SIGNED

SIGNATURE OF CO-OWNER

DATE SIGNED

* The disclosure of your social security or federal identification number is mandatory, is solicited by the authority granted by 42 U.S.C. § §405(c)(2)(C) and/or 666(a)(13)

and will be used by the Department of Motor Vehicles in the administration of motor vehicle, tax and child support laws, to identify individuals affected by such laws.

Additional Information on Reverse Side

TA-VT-19 5M 6/12 JTB