VSA 17A (07/01/2020)

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: Title and Registration (license plates issued) title on file for this vehicle. (No paper title will be issued) YES NO
Check Vehicle is owned by individual(s). If this application is for joint ownership, do you wish clear rights of ownership to be transferred to
one: Vehicle is business owned. the surviving owner in the event of the death of either the owner or co-owner? YES NO
OWNER'S FULL LEGAL NAME (last, first, mi, suffix) OR BUSINESS NAME (if business owned) TELEPHONE NUMBER DMV CUSTOMER NUMBER / FEIN / SSN

LOG NUMBER ____________________________________

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
CITY COUNTY TOWN OF military duty or service? 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)

FUEL GAS DIESEL OTHER FUEL TYPE VEHICLE PRIMARY IS THIS A LOW YES IS THIS A YES
SPEED VEHICLE? LOGGING
TYPE ELECTRIC OTHER COLOR NO VEHICLE? NO
IS VEHICLE STATE OR YES - enter agency code NO DIVISION CODE PREVIOUS TITLE NUMBER STATE
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

TITLE NUMBER ____________________________________

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
SALES PRICE PROCESSING FEE SALES AND USE TAX VEHICLE PURCHASED FROM ONLY 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)
 VSA 17A (07/01/2020) Page 2
PERSONAL PROPERTY TAX RELIEF ELIGIBILITY
1. Answer the questions below to determine if your vehicle qualifies for car tax relief. YES NO
a. Is more than 50% of the vehicle's annual mileage used as a business expense for federal income tax purposes OR reimbursed by an
employer?
b. Is more than 50% of the depreciation associated with the vehicle deducted as a business expense for federal income tax purposes?
c. Is the cost of the vehicle expensed pursuant to Section 179 of the Internal Revenue Service Code?
d. If the vehicle is leased by an individual, does the leasing company pay the tax without reimbursement from the individual?
2. If you answered YES to ANY of the above questions, check Business Use. Your vehicle is considered by State law to have a business use and does NOT
qualify for Personal Property Tax Relief. BUSINESS USE
3. If you answered NO to ALL of the above questions, check Personal Use and answer the question below.
PERSONAL USE -- Is this vehicle held in a private trust for non-business purposes by an individual beneficiary? YES NO

INSURANCE CERTIFICATION
I/We certify that (check one):
This vehicle is insured by a liability policy issued through an insurance company licensed to do business in Virginia and NAME OF INSURANCE COMPANY
it will remain insured while registered, whether or not it is operated. Penalties are severe for violation of this
requirement. Be advised that the amount of liability coverage required is higher for vehicles that are operated for hire.
This vehicle is not insured; therefore, I am remitting the applicable uninsured motor vehicle fee. (This fee provides no insurance coverage.) A vehicle must be
insured with liability coverage when it is registered, and it must remain insured while registered, whether or not it is operated, or the uninsured motor vehicle
fee must be paid. Penalties are severe for violation of this requirement.

REGISTRATION INFORMATION
NOTE: Virginia offers more than 200 unique plates for our customers. Please visit www.dmvNow.com for a listing of special plates available. Not all plates are
available for all vehicle types and some special plates require a certification form. Review our website for additional information.
REGISTRATION PERIOD (check one:) ONE YEAR TWO YEARS ($2 discount)

THREE YEARS ($3 discount - not for emissions area) TRANSFER

(enter plate number)
REGISTRATION TYPE (check one:) PRIVATE RENTAL FOR HIRE (complete For Hire Information below)
Trailer Permanent - (one time fee) select size: Regular size plate Small size plate (trailer gross weight must be 4,000 lbs or less)
Communication Impairment Indicator Option - For law enforcement purposes, I request a DMV record indicator for a disability that can impair communication.

FOR HIRE INFORMATION

Check to indicate how the vehicle being registered will be used (check all that apply). If the vehicle will be used in property carrier operations, and those
operations exclusively use passenger cars, motorcycles, autocycles, mopeds, or vehicles with a gross vehicle weight rating (GVWR) of 10,000 pounds or less,
then registration for hire is not required.
PASSENGER CARRIER OPERATIONS PROPERTY CARRIER OPERATIONS
Common Carrier - Regular Route Employee Hauler Sight-seeing Carrier Property Carrier *
Common Carrier - Irregular Route Contract Passenger Carrier Non-Emergency Medical Transport Household Goods Carrier *
Nonprofit/Tax-Exempt Taxicab Exempt Operations - Passengers * Exempt Operations - Property *
* You must also complete the For-Hire Vehicles Registration Request (MCS115)
Do you hold a valid intrastate operating authority certificate/permit? YES NO
If no, and you are a passenger carrier you must also complete the For-Hire Vehicles Registration Request (MCS115).

NOTICE
PRIVACY NOTICE: The information, including Social Security Number, is requested in accordance with Virginia Code §§46.2-623 and 46.2-629. Any person
who refuses to supply the required information will be denied a certificate of title and/or registration. By signing this form, you authorize DMV’s exchange of title
and registration records with business, law enforcement, or government entities and you authorize DMV’s exchange of title and registration records in accordance
with Va. Code §§46.2-208 through 46.2-214 and 18 U.S.C. 2721.
POWER OF ATTORNEY FOR NON-RESIDENT(S) AND CORPORATION(S) NOT DOMICILED IN VIRGINIA: Pursuant to the provisions of Virginia Code
§46.2-601, I/we appoint the Commissioner of the Department of Motor Vehicles of the Commonwealth of Virginia, to be my/our true and legal agent upon whom
all legal processes against me/us may be served in any legal proceeding arising from the operation and/or use of any motor vehicle registered in my/our name(s)
in the Commonwealth of Virginia. I/we agree that any lawful process or notice to me/us which is served on the Commissioner shall have the same legal effect as
if served on me/us within the Commonwealth of Virginia.

CERTIFICATION
I/We 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.
APPLICANT NAME (print) SIGNATURE OF APPLICANT DATE (mm/dd/yyyy)

CO-APPLICANT NAME (print) SIGNATURE OF CO-APPLICANT DATE (mm/dd/yyyy)

DMV USE ONLY

PROOF OF ADDRESS (specify proof document(s) presented)
WITH LIEN? YES NO UMV FEE $
IF HELD, REASON: CSR STAMP
SALES PRICE $ TITLE FEE $

PROCESSING FEE $ TRANSFER FEE $

SALES & USE TAX $ REGISTRATION FEE $ TOTAL $