Form Vsa 66 - Application For Transfer And Supplemental Liens Page 2

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VSA 66 (12/20/2016)

Page 2

6. CERTIFICATION

I/we hereby make application for a title certificate for the vehicle described herein and for that purpose certify and affirm that all information presented in

this form is true and correct, that any documents I/we have presented to DMV are genuine, and that the information included in all supporting

documentation is true and accurate. I/we make this certification and affirmation under penalty of perjury and I/we understand that knowingly making a

false statement or representation on this form is a criminal violation.

Owners must sign when application is made for a supplemental lien. Lienholders must sign when transferring a lien.

OWNER SIGNATURE

DATE (mm/dd/yyyy)

CO-OWNER SIGNATURE

DATE (mm/dd/yyyy)

CURRENT LIENHOLDER NAME (print)

CURRENT LIENHOLDER SIGNATURE

DATE (mm/dd/yyyy)

NEW LIEN HOLDER NAME (print)