Vsa 17 A

CERTIFICATE OF TITLE AND REGISTRATION
PURPOSE: INSTRUCTIONS: Use this form to apply for a title and/or to register a passenger vehicle, motorcycle, truck, motor home (RV), or trailer. Complete this form and return to any DMV customer service center (CSC). DMV may request proof of any information provided.
APPLICATION FOR
VSA 17A (07/01/2011)
ACQUISITION TYPE (check all that apply)

Original Title is Electronic
(No paper attached)
Court Order Replevin Seizure
Replica Reconstructed Specially Constructed
Abandoned Vehicle
(Complete VSA 40) (Complete VSA 41)
Leased Rental
Mechanic's Lien / Storage Lien Repossession

(Vehicle must be in your possession)
LOG NUMBER ____________________________________
OWNER INFORMATION
APPLICATION TYPE: Check one:
Check one (if applicable):
Title Title and Registration (license plates issued)
Electronic Title Option -- I want DMV to maintain an electronic certificate of title on file for this vehicle. (No paper title will be issued) YES NO
Vehicle is owned by individual(s). Vehicle is business owned.
If this application is for joint ownership, do you wish clear rights of ownership to be transferred to the surviving owner in the event of the death of either the owner or co-owner? YES NO
TELEPHONE NUMBER TELEPHONE NUMBER SOCIAL SECURITY NUMBER / FEIN SOCIAL SECURITY NUMBER / FEIN
OWNER'S FULL LEGAL NAME (last, first, mi, suffix) OR BUSINESS NAME (if business owned) CO-OWNER'S FULL LEGAL NAME (last, first, mi, suffix)
If you change your residence/home or mailing address to a non-Virginia address, your driver's license and/or photo identification card may be canceled.
RESIDENCE/HOME/BUSINESS ADDRESS (Apt # if applicable) MAILING ADDRESS (if different from above) OPTIONAL CO-OWNER'S RESIDENCE ADDRESS (if different from above) RESIDENCE/BUSINESS JURISDICTION CITY CITY CITY STATE STATE STATE ZIP CODE ZIP CODE ZIP CODE
LOCATION WHERE VEHICLE IS PRINCIPALLY GARAGED CITY COUNTY TOWN OF
Are any of the vehicle owners on active military duty or service? YES NO
LIEN INFORMATION
IS THERE A LIEN ON THIS VEHICLE? DATE OF FIRST LIEN (mm/dd/yyyy) LIENHOLDER MAILING ADDRESS DATE OF SECOND LIEN (mm/dd/yyyy) LIENHOLDER MAILING ADDRESS LIENHOLDER NAME CITY YES - YOU MUST COMPLETE THIS SECTION LIENHOLDER NAME CITY NO - SKIP TO THE NEXT SECTION LIENHOLDER CODE STATE ZIP CODE
LIENHOLDER CODE STATE ZIP CODE
SOURCE OF OWNERSHIP INFORMATION

HOW WAS THIS VEHICLE SOLD TO YOU? VA DEALER LICENSE NUMBER (check one) USED NEW DEMONSTRATOR VEHICLE PURCHASED FROM STREET ADDRESS CITY RENTOR NUMBER SALES PRICE PURCHASE DATE (mm/dd/yyyy) PROCESSING FEE SALES AND USE TAX STATE ZIP CODE
TITLE NUMBER ____________________________________
VEHICLE INFORMATION
YEAR MAKE GROSS WEIGHT SECONDARY MODEL GROSS VEHICLE WEIGHT RATING (GVWR) PREVIOUS TITLE NUMBER AGENCY CODE BODY TYPE VEHICLE IDENTIFICATION NUMBER (VIN) GROSS COMBINATION NUMBER OF AXLES FUEL TYPE WEIGHT RATING (GCWR) IS THIS A LOW STATE YES IS THIS A LOGGING SPEED VEHICLE? VEHICLE? NO NAME OF UNIT HAVING OPERATIONAL CONTROL
EMPTY WEIGHT VEHICLE COLOR
PRIMARY
YES NO
IS VEHICLE STATE OR LOCALITY-OWNED?
YES - enter agency code NO
PERSONAL PROPERTY TAX RELIEF ELIGIBILITY (Passenger vehicles only)

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
VSA 17A (07/01/2011) Page 2
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 IN EXCESS of its mechanical limits. The odometer reading above is NOT the ACTUAL MILEAGE. (WARNING: Odometer discrepancy.) 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)
REGISTRATION INFORMATION
REGISTRATION PERIOD (check one:) ONE YEAR TWO YEARS ($2 discount applies) REGISTRATION TYPE (check one:) PRIVATE RENTAL TRANSFER PLATE
PLATE NUMBER TO TRANSFER
TYPE OF PLATE REQUESTED

New Plates (check one) Standard (Blue and White) Heritage (Dogwood-Cardinal) Scenic (check one) Mountain to Patriot Seashore Great Seal Antique - Not General Transportation Use Autumn Black & White Yellow Vintage - Not General Transportation Use Vintage - General Transportation Use
(Antique plates require certification, (VSA 10B) and may be purchased for a passenger vehicle, trailer, or motorcycle.)
Permanent Plates - may be issued to trailers, travel trailers, or semi-trailers; trucks/tractor trucks with a GVWR or GCWR of more than 26,000 lbs.; trucks/tractor trucks with GVWR or GCWR of 7,501 to 26,000 lbs. if used for business only or farming. Trailer Permanent - one-time fee (check one) Regular size plate Small size plate (trailer gross weight must be 4,000 lbs or less)
LEASED VEHICLE INFORMATION

Do you wish to have the vehicle renewal card mailed to the lessee?
LESSEE'S FULL LEGAL NAME (last, first, mi, suffix) RESIDENCE/HOME ADDRESS (Apt # if applicable) CITY
YES
NO
If YES, provide the information requested below.
CO-LESSEE'S FULL LEGAL NAME (last, first, mi, suffix) STATE ZIP CODE
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.
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 it will remain insured while registered, whether or not it is operated. Penalties are severe for violation of this requirement. 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.
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.
SIGNATURE OF APPLICANT SIGNATURE OF APPLICANT DATE (mm/dd/yyyy) DATE (mm/dd/yyyy)
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. Title and registration records may be disseminated in accordance with 46.2-208 through 46.2-214, to business, law enforcement or authorized government entities.
PROOF OF ADDRESS (specify proof document(s) presented ) PLATE EXPIRATION TYPE DATE TRANSFER FEE $ REGISTRATION FEE $ WEIGHT INCREASE $ FEE PERSONALIZED $ PLATE FEE UMV FEE $ DEALER $ SURCHARGE TOTAL $
DMV USE ONLY

IF HELD, REASON: CSR STAMP
WITH LIEN? PLATE NUMBER
YES
NO
SALES PRICE $ PROCESSING FEE $ SALES & USE TAX $ TITLE FEE $

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CERTIFICATE OF TITLE AND REGISTRATION

VSA 17A (07/01/2011)

ACQUISITION TYPE (check all that apply)

Court Order Replevin Seizure

Replica Reconstructed Specially Constructed

Mechanic's Lien / Storage Lien Repossession

LOG NUMBER ____________________________________

Title Title and Registration (license plates issued)

Vehicle is owned by individual(s). Vehicle is business owned.

LOCATION WHERE VEHICLE IS PRINCIPALLY GARAGED CITY COUNTY TOWN OF

LIENHOLDER CODE STATE ZIP CODE

SOURCE OF OWNERSHIP INFORMATION

TITLE NUMBER ____________________________________

EMPTY WEIGHT VEHICLE COLOR

IS VEHICLE STATE OR LOCALITY-OWNED?

YES - enter agency code NO

PERSONAL PROPERTY TAX RELIEF ELIGIBILITY (Passenger vehicles only)

VSA 17A (07/01/2011) Page 2

TYPE OF PLATE REQUESTED

LEASED VEHICLE INFORMATION

If YES, provide the information requested below.

POWER OF ATTORNEY FOR NON-RESIDENT(S) AND CORPORATION(S) NOT DOMICILED IN VIRGINIA

DMV USE ONLY

WITH LIEN? PLATE NUMBER

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