Form Hsmv 82101 - Application For Duplicate Or Lost In Transit/reassignment - 2011
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1
2STATE OF FLORIDA
DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES
DIVISION OF MOTORIST SERVICES
SUBMIT THIS FORM TO YOUR LOCAL TAX COLLECTOR OFFICE
APPLICATION FOR DUPLICATE OR LOST IN TRANSIT/REASSIGNMENT FOR A
MOTOR VEHICLE, MOBILE HOME OR VESSEL TITLE CERTIFICATE
1
TYPE OF APPLICATION
VEHICLE/VESSEL DUPLICATE WITH TRANSFER:
VEHICLE/VESSEL
VEHICLE/VESSEL
(Both parties must be present for this transaction)
DUPLICATE:
LOST IN TRANSIT:
(Fee Required)
OR
AND NOTE: When joint ownership, please indicate if “or” or
NOTE: No fee required if vehicle application
“and” is to be shown on the title when issued. If neither box is checked, the
LOST
STOLEN
is made within 180 days from last title
title will be issued with “and”.
issuance date and has been lost in mailing.
Damaged
(Certificate of Title must be submitted)
NOTE: An indication of lost, stolen or damaged is required.
OWNER’S NAME
Owner’s E-Mail Address
PURCHASER’S NAME
Purchaser’s E-Mail Address
(Last, First, Middle Initial)
(Last, First, Middle Initial)
CO-OWNER’S NAME
Co-Owner’s E-Mail Address
CO-PURCHASER’S NAME
Co-Purchaser’s E-Mail Address
(Last, First, Middle Initial)
(Last, First, Middle Initial)
OWNER’S MAILING ADDRESS
PURCHASER’S MAILING ADDRESS
CITY
STATE
ZIP
CITY
STATE
ZIP
CAUTION: IF ADDRESS DIFFERS FROM DMV RECORDS,
DATE OF BIRTH
PURCHASER’S DL/ID #
CO-PURCHASER’S DL/ID#
ADDRESS VERIFICATION MUST BE SUBMITTED
2
APPLICATION FOR DUPLICATE IS MADE BY:
MOTOR VEHICLE MOBILE HOME OR RECREATIONAL VEHICLE DEALER/
AUCTION LICENSE NUMBER (
LIENHOLDER DATE OF LIEN
DEALER/AUCTION LICENSE NUMBER DOES NOT APPLY TO VESSELS:
LIENHOLDER OR DEALER/AUCTION NAME:
Owner
ADDRESS:
CITY:
STATE:
ZIP:
3
MOTOR VEHICLE, MOBILE HOME OR VESSEL DESCRIPTION
Vehicle/Vessel Identification Number
Make/Manufacturer
Year
Body
Color
License Plate or Vessel Registration Number
Florida Title Number
4
VEHICLE USAGE/BRANDS
LONG TERM LEASE
POLICE VEHICLE
PRIVATE USE
FLOOD
SHORT TERM LEASE
TAXI
REPLICA
KIT CAR
REBUILT
ASSEMBLED FROM PARTS
MANUFACTURER’S BUY BACK
5
LIENHOLDER INFORMATION
If no lien, Print “None”
Date of Lien
Lienholder Name
FEID #
DL# & Sex and Date of Birth
DMV Account #
Lienholder E-Mail Address
Lienholder Mailing Address
City
State
Zip
If Lienholder authorizes the Department to send title to the owner, check box and countersign.
If this box is not checked, title will be mailed to the first lienholder.
(DOES NOT APPLY TO VESSELS)
(Signature of Lienholders Representative)
6
APPLICATION ATTESTMENT/SIGNATURES AND ODOMETER DECLARATION/DISCLOSURE
WARNING: Federal and state law require that you state the mileage in connection with an application for Certificate of Title. Providing a false statement may result in fines or imprisonment.
,
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/OUR KNOWLEDGE THE ODOMETER READING:
CAUTION: READ CAREFULLY BEFORE YOU CHECK A BOX
1. REFLECTS ACTUAL MILEAGE.
2. IS IN EXCESS OF ITS MECHANICAL LIMITS. (EXCESS OF ITS MECHANICAL LIMITS APPLIES TO 5 DIGIT ODOMETERS)
3. IS NOT THE ACTUAL MILEAGE. WARNING - ODOMETER DISCREPANCY
I CERTIFY THAT THE MOTOR VEHICLE/VESSEL DESCRIBED ABOVE WILL NOT BE OPERATED ON THE STREETS AND HIGHWAYS/WATERWAYS OF
THIS STATE AND NO FLORIDA LICENSE PLATE HAS BEEN TRANSFERRED TO OR PURCHASED FOR THIS MOTOR VEHICLE.
I am/we are the owner(s), lienholder(s), and am legally authorized to apply for and receive the Duplicate Certificate of Title. I/we further agree to
indemnify the Department and defend the Certificate of Title against all actions or claims by any person.
UNDER PENALTIES OF PERJURY, I/WE DECLARE THAT I/WE HAVE READ THE FOREGOING DOCUMENT AND THAT THE FACTS STATED IN IT ARE TRUE.
IF APPLICABLE, I ATTEST TO HAVING
Date Sold
Selling Price $
ACQUIRED THE MOTOR VEHICLE, MOBILE
PURCHASE
GIFT
INHERITANCE
COURT ORDER
HOME OR VESSEL DESCRIBED ABOVE BY:
Signature of
Printed Name
Purchaser:
_______________________________________________________________________
of Purchaser: _______________________________________________________________________
Signature of
Printed Name of
Co-Purchaser: _____________________________________________________________________
Co-Purchaser’s: _____________________________________________________________________
Signature of Seller/
Printed Name of
X
Owner/Lienholder: __________________________________________________________________
Seller/ Owner/Lienholder: ______________________________________________________________
Printed Name of
Signature of
Co-Owner: __________________________________________________________________________
Co-Owner: ________________________________________________________________________
7
FOR FLORIDA DMV OR TAX COLLECTOR/LICENSE PLATE AGENCY USE ONLY
Signature
Printed Name
County
Agency #
Date Completed
Duplicate authorization
verification completed
HSMV 82101 (Rev. 06/11) S
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