Vsa 66 Form PDF Details

If you are a veteran or the dependent of a veteran, you may be eligible for benefits through the Veterans Service Agency (VSA). The VSA 66 form is your application for these benefits. In order to qualify, you must provide proof of your military service and meet certain other requirements. This guide will help you understand the process and complete the VSA 66 form accurately.

This general report will help you establish the time it will require you to complete vsa 66 form, how many pages it has, and a handful of additional specific details about the PDF.

QuestionAnswer
Form NameVsa 66 Form
Form Length2 pages
Fillable?Yes
Fillable fields1
Avg. time to fill out42 sec
Other namesdmv supplemental liens, virginia dmv vsa, va dmv form vsa 67, va dmv duplicate title form vsa 67

Form Preview Example

APPLICATION FOR

VSA 66 (06/25/2016)

SUPPLEMENTAL AND TRANSFER LIENS OR

 

REPLACEMENT AND SUBSTITUTE TITLES

 

Purpose: Use this form to apply for a supplemental lien, lien transfer, replacement title certificate or substitute title certificate.

Instructions: Submit this form to any DMV customer service center with the appropriate fees. You may also mail the form and fees to the Titling Work Center at the address above.

APPLICATION TYPE

CHECK ONE:

Supplemental Lien: Submit an original title unless the new lienholder is the same as the old lienholder and the lienholder is a participant in the electronic title program. Complete the (1) Owner Information, (2) Vehicle Information, (3) Current Lien Information, (4) Supplemental Lien, and (7) Signatures sections.

Transfer of Lien: Submit an original title unless the lienholder is a participant in the electronic title program. Complete the (1) Owner Information, (2) Vehicle Information, (3) Current Lien Information, and (5) Transfer of Lien sections.

Replacement Title Certificate: Will be issued only if the original is lost, mutilated or illegible. Once a replacement has been issued, any prior title is invalid. Complete the (1) Owner Information and (2) Vehicle Information sections. Complete the (3) Current Lien Information, and (7) Signatures sections, if applicable.

Check one: (required)

 

Lost

 

Mutilated

 

Illegible

 

 

 

Substitute Title Certificate: Will be issued if there is a change in the information on the title. Complete the (1) Owner Information, (2) Vehicle Information,

(6)Substitute Title Certificate Information, and (7) Signatures sections. Complete the (3) Current Lien Information, if applicable.

Check if applicable: (optional) Beneficiary Information - Complete VSA 18 to add/change/remove a beneficiary

1.

 

 

 

 

 

 

OWNER INFORMATION

 

 

 

 

 

 

 

OWNER FULL LEGAL NAME (last, first, middle, suffix)

 

 

 

 

 

 

 

 

 

 

TELEPHONE NUMBER

DMV CUSTOMER NUMBER / FEIN / SSN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

)

 

 

 

 

 

 

 

 

CO-OWNER FULL LEGAL NAME (last, first, middle, suffix)

 

 

 

 

 

 

 

 

 

TELEPHONE NUMBER

DMV CUSTOMER NUMBER / FEIN / SSN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

)

 

 

 

 

 

 

 

 

MAILING ADDRESS

 

 

 

 

 

 

CITY OR TOWN

 

 

 

 

 

 

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are any of the vehicle owners on active military duty or service?

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

VEHICLE INFORMATION

 

 

 

 

 

 

 

VEHICLE IDENTIFICATION NUMBER (VIN)

TITLE NUMBER

 

 

 

 

 

 

 

PLATE NUMBER

PLATE TYPE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YEAR

MAKE

MODEL

 

 

 

 

 

 

 

 

 

 

 

 

 

BODY TYPE

 

 

 

 

WEIGHT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

CURRENT LIEN INFORMATION

 

 

 

 

 

 

 

CHECK ONE:

 

Printed original title certificate attached

 

 

 

 

Original title certificate is electronic title (no paper title attached)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIENHOLDER NAME

 

 

 

 

 

 

 

 

 

 

 

 

LIENHOLDER CODE

 

 

LIEN DATE (mm/dd/yyyy)

FIRST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIEN

 

 

LIENHOLDER MAILING ADDRESS

 

 

 

 

CITY OR TOWN

 

 

 

 

 

 

STATE

 

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIENHOLDER NAME

 

 

 

 

 

 

 

 

 

 

 

 

LIENHOLDER CODE

 

 

LIEN DATE (mm/dd/yyyy)

SECOND

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIEN

 

 

LIENHOLDER MAILING ADDRESS

 

 

 

 

CITY OR TOWN

 

 

 

 

 

 

STATE

 

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

SUPPLEMENTAL LIEN

 

 

 

 

 

 

 

Complete this section if you wish to add a lien. The priority of the security interest will be determined according to the date of the application filing (Virginia Code

§ 46.2-637).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIENHOLDER NAME

 

 

 

 

 

 

 

 

 

LIENHOLDER CODE

 

DATE OF LIEN FILING (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAILING ADDRESS

 

 

CITY OR TOWN

 

 

 

 

 

 

 

 

 

STATE

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

TRANSFER OF LIEN

 

 

 

 

 

 

 

Complete this section only if you wish to transfer a lien.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIENHOLDER NAME

 

 

 

 

 

 

 

 

 

LIENHOLDER CODE

 

DATE OF LIEN FILING (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAILING ADDRESS

 

 

CITY OR TOWN

 

 

 

 

 

 

 

 

 

STATE

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The undersigned lienholder acknowledges this to be a free and voluntary act.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIENHOLDER NAME

 

 

 

 

BY (Signature)

 

 

 

 

 

 

 

 

 

DATE (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NEW LIEN HOLDER NAME

 

 

 

 

BY (Signature)

 

 

 

 

 

 

 

 

 

DATE (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

<![endif]>LOG NUMBER __________________________ TITLE NUMBER _________________________________

6.

SUBSTITUTE TITLE CERTIFICATE

Complete this section only when information on the previously issued certificate of title changes.

NAME OF DOCUMENT(S) SUBMITTED TO MAKE CHANGE:

See page 2 for additional information on replacement title certificate

VSA 66 (06/25/2016)

Page 2

7.SIGNATURES

ANY WILLFUL MISINFORMATION GIVEN WITH FRAUDULENT INTENT MAY BE PUNISHABLE BY LAW.

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 and a substitute original title certificate. (Lienholders must sign in the Transfer of Liens section.)

OWNER SIGNATURE

DATE (mm/dd/yyyy)

CO-OWNER SIGNATURE

DATE (mm/dd/yyyy)

REPLACEMENT TITLE CERTIFICATE DELIVERY PROCEDURES

1.NO OUTSTANDING LIEN: The replacement title certificate will be mailed to the vehicle owner unless a person presenting the owner's application can provide identification and is the owner's authorized representative.

2.OUTSTANDING LIEN: The replacement title certificate will be mailed to the lienholder if a recorded lien has not been satisfied. For evidence of lien satisfaction, the lienholder must indicate on the face of the title that the lien has been satisfied. The lienholder must sign the lien satisfaction. The title should then be forwarded to the owner. An original of a signed lien satisfaction on a lending institution's letterhead or from an individual lienholder is sufficient evidence of lien satisfaction. A lienholder may apply for a replacement title without obtaining the owner(s) signature(s).

Lienholder's Signature:

INSTRUCTIONS FOR REPLACEMENT TITLE CERTIFICATE ONLY

1.Complete Application Form VSA-66, and pay the fee.

2.If the person returning the completed Form VSA-66, is not the owner or a lienholder, the owner must submit this form with the following written authorization.

3.Authorized person accepting replacement title certificate for owner must present identification.

AUTHORIZATION FOR RECEIPT OF CERTIFICATE OF TITLE

I

authorize

 

 

 

 

(Name of Vehicle Owner)

 

 

(Name of Authorized Representative)

to receive the replacement title certificate.

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

(Owner's Signature)

 

MM / DD / YYYY

 

 

 

 

PRIVACY ACT NOTICE

The information, including Social Security Number, is requested in accordance with §46.2-623 (Code of Virginia). 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.

FOR DMV USE ONLY

TITLE RELEASED TO

DATE (mm/dd/yyyy)

TYPE OF IDENTIFICATION PRESENTED

NUMBER OF IDENTIFICATION PRESENTED

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completing va vsa 66 part 1

Type in the required details in the section FIRST, LIEN SECOND, LIEN LIEN, HOLDER, NAME LIEN, HOLDER, CODE LIEN, DATE, mm, dd, yyyy LIEN, HOLDER, MAILING, ADDRESS CITY, OR, TOWN STATE, ZIP, CODE LIEN, HOLDER, NAME LIEN, HOLDER, CODE LIEN, DATE, mm, dd, yyyy LIEN, HOLDER, MAILING, ADDRESS CITY, OR, TOWN and STATE.

va vsa 66 FIRSTLIEN, SECONDLIEN, LIENHOLDERNAME, LIENHOLDERCODE, LIENDATEmmddyyyy, LIENHOLDERMAILINGADDRESS, CITYORTOWN, STATE, ZIPCODE, LIENHOLDERNAME, LIENHOLDERCODE, LIENDATEmmddyyyy, LIENHOLDERMAILINGADDRESS, CITYORTOWN, and STATE fields to complete

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step 3 to entering details in va vsa 66

As part of paragraph DATE, mm, dd, yyyy CO, OWNER, SIGNATURE DATE, mm, dd, yyyy and Lien, holders, Signature identify the rights and responsibilities.

Filling out va vsa 66 stage 4

Finish by reviewing the following areas and filling them in as required: Name, of, Vehicle, Owner authorize, Name, of, Authorized, Representative Owners, Signature Date, MM, DD, YYYY PRIVACY, ACT, NOTICE TITLE, RELEASED, TO FORD, MV, USE, ONLY DATE, mm, dd, yyyy TYPE, OF, IDENTIFICATION, PRESENTED and NUMBER, OF, IDENTIFICATION, PRESENTED

stage 5 to filling out va vsa 66

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