VR-217 (05-21)

6601 Ritchie Highway, N.E.

Glen Burnie, Maryland 21062

For more information, please call: 410-768-7000 (to speak with a customer agent).

TTY for the hearing impaired: 1-800-492-4575. Visit our website at: www.MVA.Maryland.gov

VR-217

(05-21)

Please print or type all information in black ink.

Notice to secured party:

To perfect your security interest: (Maryland title must accompany two copies of this form)

The security interest as set forth below is perfected on date of creation if this statement, ﬁling fee, and any other information required is delivered to

the Motor Vehicle Administration within ten days from the date this security interest was created. If delivery is made after the tenth day, the date of

perfection is the date received by the Motor Vehicle Administration.

Please Note: If the lien holder is anyone other than a bona ﬁde lending institution (i.e. bank, credit union, ﬁnance company or dealer), a lien contract

must accompany this form.

Vehicle to be held as collateral

Year Make of Vehicle Body Style Vehicle Identication Number Maryland Title Number

Type of Contract Account Number (MVA Use Only) Lien Code

Name of Secured Party Date of Creation Amount of Lien

Street Address of Secured Party City County State Zip Code

Name of Debtor

Street Address of Debtor City County State Zip Code

I (we) certify under penalty of perjury that:

A. The lien holder making application has a Maryland lender’s license or sales nance license issued by the Commissioner of Financial, Regulation,

License No. _____________________________________ or

B. The lien holder making application is exempt from obtaining a Maryland lender’s license or sales nance license because the lien holder is a:

 Bank  National Banking Association  Trust Company  Savings Bank  Savings and Loan Association  Credit Union

 Licensed Dealer (a seller of goods or services not engaged in making loans or acting as a credit service business)

 Other person who is not in the business of making loans.

Signature of Lien Holder’s Authorized Agent _________________________________ Date __________________

Printed Name of Authorized Agent _________________________________________ Title __________________

For MVA Use Only

Assignment of Security Interest

Name of Assignee

Street Address of Assignee City County State Zip Code

Amount of Security Interest Assigned

Full Amount

Date Assigned

Partial Amount

We, the undersigned, certify, under penalty of perjury, that the security interest set forth above has been assigned by

the original secured party named herein to the assignee indicated.

Signature of Original Secured Party Date

Signature of Assignee Date

Security Interest Filing Statement (Filing Fee: $20.00)

The MVA should contact me at: ________________________________________ or _______________________ for any questions regarding this application.

(Email address) (Phone)

FEIN