82040

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1 FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES APPLICATION FOR CERTIFICATE OF TITLE WITH/WITHOUT REGISTRATION LOCAL TAX COLLECTOR OFFICE YOUR SUBMIT THIS FORM TO www.flhsmv.gov/offices/ T RANSFER VEHICLE TYPE : MOTOR VEHICLE MOBILE HOME VESSEL OFF-HIGHWAY VEHICLE : O RIGINAL ROV MC : CHECK APPLICATION TYPE ATV OWNER / APPLICANT INFORMATION 1 you Customer Number Check this box if Fleet Number Unit Number are requesting Co Owner Owner - the certificate of title to be printed. yes no no yes Are you a Florida resident? yes no yes Are you an alien? no I iiiiii AN NOTE: When joint ownership, please indicate if “or” or “and” is to be shown on title when issued. If neither box is checked, the title will be issued with "and." OR D With Rights of Survivorship Tenancy By the Entirety Owner's County of Residence: _______________ ______________________ Life Estate/Remainder Person If applicable: r’s Email Address irth Owne Date of B Last Name) & Sex ppears on Driver License (First, Full Middle/Maiden, FL Driver License or FEID/Suffix # Owner’s Name As It A -Owner’s/Lessee’s Email Address Last Name) Date of Birth -Owner/Lessee’s Name As It Appears on Driver License (First, Full Middle/Maiden, & Sex FL Driver License or FEID/Suffix # Co Co City Owner’s Mailing Address (Mandatory unless a m State ember of the Military) Zip Co Lessee’s Mailing Address (Mandatory unless a member of the Military) -Owner’s/ State Zip City State /Lessee’s Physical Street Address in Florida Zip Owner’s (Mandatory unless a member of the Military) City Zip Mobile Home Physical Address (if applicable) Check if in a mobile home rental park with 10 or more lots. State City \ \ Date of Birth Sex Mail To Customer’s Email Address FL Driver License or FEID/Suffix # Mail To Customer Name (If different From Above Owner) State Mail To Customer Address (If different From Above Mailing Address) City Zip MOTOR VEHICLE , MOBILE HOME OR VESSEL DESCRIPTION 2 Vehic Make/Manufacturer Year Body Color Florida Title Number le/Vessel Identification Number Length VAN USE, IF APPLICABLE Previous State of Issue BHP/CC Weight GVW/LOC License Plate or Vessel Registration Number Ft. In. PASSENGER OTHER PROPULSION TYPE HULL MATERIAL FUEL DRAFT OF VESSEL * ( The depth of water a Personal Watercraft Open Motorboat Gas Wood Aluminum Houseboat Sail Outboard vessel draws) Pontoon Canoe Steel Air Propelled Inboard Fiberglass Cabin Motorboat Diesel _________ Inboard/Outboard Electric Other Wood/Fiberglass Airboat iliary Sailboat Aux FT. ______ IN. ______ Inflatable Other__________________________ Other_________________ Specify Other______________________ Sailboat * For all vessels 26’ or more in Specify Specify Specify length and all sailboats USE OF VESSEL PREVIOUS OUT STATE -OF- Commercial Sponge Recreational (Pleasure) Commercial Blue Crab Commercial Stone Crab Government REGISTRATION NUMBER: Commercial Shrimp Recip. Commercial Fish Commercial Other ial Live Bait Commerc Commercial Charter ______________ Dealer/Manuf. Commercial Spiney Lobster Hire (Livery) Commercial Mackerel Commercial Shrimp Non- Recip. Exempt Commercial Oyster Previously Federally Documented Vessel, Attach Copy of: State of Principal Use or .S. Coast Guard Release From Documentation Form; Copy of Canceled Documentation Papers U BRANDS, USAGE AND TYPE (Check Applicable Boxes) 3 LONG TERM SHORT TERM LEASE CUSTOM REBUILT ILEV POLICE VEHICLE FLOOD TAXI CAB LEASE PRIVATE USE ASSEMBLED FROM PARTS REPLICA GLIDER KIT AUTONOMOUS KIT CAR MANUF. BUY BACK BONDED TITLE STREET ROD ELECTRIC LIENHOLDER INFORMATION 4 Date of Lien Lienholder's Name CHECK FEID # DL # and Sex and Date of Birth DMV Account # IF ELT CUSTOMER Lienholder’s Email Address Lienholder's Address City S tate Zip : ________________________________________________________________________ If Lienholder authorizes the Department to send the motor vehicle or mobile home title to the owner, check box and countersign (Signature of Lienholder’s Representative) (Does not apply to vessels). If box is not checked, title will be mailed to the first lienholder. TRANSFER TYPE 5 IF OWNERSHIP HAS TRANSFERRED, HOW AND WHEN WAS THE VEHICLE, MOBILE HOME, OR VESSEL ACQUIRED? _________/___________/ GIFT REPOSSESSION COURT ORDER OTHER (SPECIFY) __________________________________________ SALE ______________ DATE ACQUIRED ODOMETER DECLARATION 6 WARNING: Federal and State law requires that you state the mileage in connection with an application for a Certificate of Title. Failure to complete or providing a false statement may result in fines or imprisonmen t. I/WE STATE THAT THIS 5 OR 6 DIGIT ODOMETER NOW READS , . XX (NO TENTHS) MILES, DATE READ _____ /_____ / ________ AND I/WE HEREBY CERTIFY THAT TO THE BEST OF MY E THE ODOMETER READING: KNOWLEDG /OUR REFLECTS ACTUAL MILEAGE. 2. IS IN EXCESS OF ITS MECHANICAL LIMITS. 3. IS NOT THE ACTUAL MILEAGE. 1. DEALER SALES TAX REPORT AND VEHICLE TRADE IN INFORMATION (IF APPLICABLE) 7 FLORIDA SALES TAX REGISTRATION NUMBER DEALER LICENSE NUMBER DATE OF SALE AMOUNT OF TAX DEALER / AGENT SIGNATURE TITLE NUMBER MAKE OF TRADE IN N) YEAR OF TRADE IN VEHICLE IDENTIFICATION NUMBER OF TRADE IN OF TRADE IN (IF KNOW www.flhsmv.gov 15C-21.001, F AC HSMV 82040 – REV. 1 1 /1 5 RULE

2 TION NUMBER VERIFICATION MOTOR VEHICLE IDENTIFICA 8 HIS SECTION REQUIRES A PHYSICAL INSPECTION AND A VERIFICATION OF THE VEHICLE IDENTIFICATION NUMBER (VIN) T TOR VEHICLES MANUFACTURED (OR THE MOTOR NUMBER FOR MO PRIOR TO 1955 OF THE MOTOR VEHICLE DESCRIBED ON THIS FORM BY A LICENSED DEAL F MOTOR VEHICLES ER, FLORIDA NOTARY PUBLIC, POLICE ) OFFICER, OR FLORIDA DIVISION O SUBMITTED ON TH ALER, THE VERIFICATION MUST BE EIR LETTERHEAD EMPLOYEE OR TAX COLLECTOR EMPLOYEE. IF THE VIN IS VERIFIED BY AN OUT OF STATE MOTOR VEHICLE DE S OR MORE) NOT CURRENTLY S TATIONERY. COMPLETE THIS SECTION ON ALL USED MOTOR VEHICLES, INCLUDING TRAILERS, (WITH ABBREVIATION OF "TL" WITH A WEIGHT OF 2,000 POUND ITLED IN FLORIDA. T mber to be : I, the undersigned, certify that I have physically inspected t he above described vehicle and find the vehicle identification nu (Vehicle Identification Number) __________________________________ ___________________________________________________________________________ ____________ _________________________________________________________________________________ PRINTED NAME DATE SIGNATURE Badge # or Florida Dealer # ______________________ Notary Stamp or Seal Law Enforcement Officer or Flor ida Dealer/Agency Name _______________________________________________________ Florida Compliance Examiner/Inspector Badge or ID Number ___________________________ ______________________________________________ FL DMV/Tax Collector Employee C OMMISSIONED NAME OF FLORIDA NOTARY : __________________________________________________ NOTARY 'S SIGNATURE ________________ _________________________________ (Print, Type or Stamp) SALES TAX EXEMPTION CERTIFICATION 9 HE PURCHASE OF A RECREATIONAL VEHICLE TO BE OFFERED FOR RENT AS LIVING ACCOMMODATIONS DOES NOT QUALIFY FOR EXEMPTION. I CERTIF Y THE RECREATIONAL VEHICLE, MOBILE HOME OR VESSEL DESCRIBED HAS T THE SALES TAX IMPOSED BY CHAPTER 212, FLOR BEEN PURCHASED AND IS EXEMPT FROM IDA STATUTES, BY: CONSUMER’S CERTIFICATE OF EXEMPTION NUMBER C.) HOLDS VALID EXEMPTION CERTIFICATE PURCHASER (STATE AGENCIES, COUNTIES, ET MOBILE HOME VESSEL WILL BE USED EXCLUSIVELY FOR RENTAL MOTOR VEHICLE SALES TAX REGISTRATION NUMBER : INHERITANCE GIFT I hereby certify that ownership of the motor vehicle, mobile home or vessel described on this application, is not subject to Florida Sales and Use Tax for the following reason DIVORCE DECREE TRANSFER BETWEEN A MARRIED COUPLE EVEN TRADE OR TRADE DOWN (State the facts of the even trade or trade down and the transferor information, including ddress, below under "Other: Explain.") the transferor's name and a OTHER: (EXPLAIN) REPOSSESSION DECLARATION 0 1 IF CHECKED, THE FOLLOWING CERTIFICATIONS ARE MADE BY THE APPLICANT: HOME OR VESSEL WAS REPOSSESSED UPON DEFAULT IN THE TERMS OF THE LIEN INSTRUMENT AND I S NOW IN MY POSSESSION. I CERTIFY THAT THIS MOTOR VEHICLE, MOBILE (VESSEL) A PHOTOCOPY OF THE LIEN INSTRUMENT FOR THE VESSEL IS REQUIRED AND ATTACHED. I AM REQUESTING THAT AN ORIGINAL R VEHICLE OR MOBILE HOME IN LIEU OF A TITLE (REPOSSESSION). CERTIFICATE OF REPOSSESSION BE ISSUED FOR THE MOTO I AM REQUESTING THAT A DUPLICATE CERTIFICATE OF REPOSSESSION BE ISSUED FOR THE MOTOR VEH ICLE OR MOBILE HOME, AS THE ORIGINAL HA S BEEN LOST OR DESTROYED. NON-USE AND OTHER CERTIFICATIONS 11 IF CHECKED, THE FOLLOWING CERTIFICATIONS ARE MADE BY THE APPLICANT: I CERTIFY THAT THE CERTIFICATE OF TITLE IS LOST OR DESTROYED. ND HIGHWAYS OF THIS STATE UNTIL PROPERLY REGISTERED . THE VEHICLE IDENTIFIED WILL NOT BE O PERATED ON THE STREETS A ATE UNTIL PROPERLY REGISTERED. THE VESSEL IDENTIFIED WILL NOT BE OPER ATED ON THE WATERS OF THIS ST OTHER: (EXPL AIN) _________________________________________________________________________________________________________________________________________________________ A PPLICATION ATTESTMENT AND SIGNATURES 12 R AGREE TO DEFEND THE TITLE AGAINST ALL CLAIMS. I/WE PHYSICALLY INSPECTED THE ODOMETER/VIN AND FURTHE (More than one form HSMV 82040 may be used for additional signatures.) UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING DOCUMENT AND THAT THE FACTS STATED IN IT ARE TRUE. _________________________________________________________________________________________________ _____________________________ ____________________________________________________________________ Date SIGNATURE OF APPLICANT (CO-OWNER) Date SIGNATURE OF APPLICANT (OWNER) RELEASE OF SPOUSE OR HEIRS INTEREST 1 3 That _________________________________________________________________________ died on _____________________________. state(s) as f ollows: The undersigned person(s) (Name of Deceased) (Date) testate (with a will) intestate (without a will) and left the surviving heir(s) named below. When applicable, the heir(s) (named below) certifies that the certificate of title is lost or destroyed. UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING DOCUMENT AND THAT THE FACTS STATED IN IT ARE TRUE. ( More than one form HSMV 82040 may be used for additional signatures.) Print or Type Name of Spouse, Co-owner or Heir(s) Signature of Spouse, Co-Ow ner or Heir(s) ______________________________________________ __________________________________ ________________________________________________________________________________ ______________________________________________ __________________________________ ________________________________________________________________________________ ______________________________________________ __________________________________ ________________________________________________________________________________ cle, mobile home or vessel described in section 2 of this for m. The person(s) signing above hereby releases all of his/her/their right, title, interest and claim as That at the time of death the decedent was owner of the motor vehi he aforesaid motor vehicle, mobile home or vessel to: heir(s) at law, legatee(s), devisee(s), or otherwise to t Name of Applicant(s) (Print or Type) AND ALL REQUIRED DOCUM ENTATION TO E, SHOULD SUBM IT THIS FORM RESIDENTS OF FLORIDA AND ALL VESSEL OWNERS, RESI DING IN FLORIDA OR OUT OF STAT IN THE APPLICANT'S CO A LOCAL FLORIDA TAX COLLECTOR’S OFFICE OR THE FLORIDA TAX COLLECTOR'S OFFICE LOCATED UNTY OF RESIDENCE FOR PROCESSING. t pages or visit the following we Check your local phone book governmen : http://www.flhsmv.gov/offi ces/ bsite for current mailing addresses www.flhsmv.gov RULE 15C-21.001, F AC HSMV 82040 – REV. 1 1 /1 5

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