Form Hsmv 82139 - Application For Notice Of Lien / Reassignment Of Lien Or Notice To First Lienholder Of Subsequent Lien
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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 NOTICE OF LIEN / REASSIGNMENT OF LIEN OR
NOTICE TO FIRST LIENHOLDER OF SUBSEQUENT LIEN
SECTIONS 1 AND 2 SHOULD BE COMPLETED IF ADDING AN ORIGINAL LIEN.
MOTOR VEHICLE
MOBILE HOME
SECTIONS 1 AND 3 SHOULD BE COMPLETED IF REASSIGNING A LIEN.
SECTIONS 1, 2 AND 4 SHOULD BE COMPLETED IF ADDING A SUBSEQUENT LIEN.
OFF-HWY VEHICLE
VESSEL
1) DESCRIPTION OF MOTOR VEHICLE, MOBILE HOME, OFF-HIGHWAY VEHICLE OR VESSEL DESCRIPTION
IDENTIFICATION NUMBER
VESSEL REGISTRATION NUMBER
MAKE/MANUFACTURER
YEAR
MODEL
WT.-LGTH.-BHP
COLOR
TYPE
USE
CERTIFICATE OF TITLE NUMBER
PREVIOUS ISSUE DATE
LICENSE PLATE NUMBER
2) NOTICE OF LIEN - LIENHOLDER INFORMATION
FEID#
Driver License Number and Sex and Date of Birth
DMV Account#
DATE OF LIEN
LIENHOLDER NAME
LIENHOLDER’S E-MAIL ADDRESS
LIENHOLDER ADDRESS
CITY
STATE
ZIP CODE
Electronic title and lien participant (Electronic title only).
If the lienholder authorizes the department to send title to the owner, _____________________________________________________________
check box and countersign. (DOES NOT APPLY TO VESSELS)
Signature of Lienholder’s Representative
One of the following boxes must be checked.
A security agreement, retain title contract, conditional bill of sale, chattel mortgage or other similar instrument was executed prior to the filing of this
notice of lien.
This notice of lien is being filed before a security agreement, retain title contract, conditional bill of sale, chattel mortgage or other similar instrument
is being executed.
Date
_____________________________
UNDER PENALTIES OF PERJURY, I (WE) DECLARE THAT I (WE) HAVE READ THE FOREGOING
DOCUMENT AND THAT THE FACTS STATED IN IT ARE TRUE.
__________________________________________________________ ______________________________________________________________
Signature of Registered Owner
Signature of Registered Co-Owner
__________________________________________________________ ______________________________________________________________
Print Name of Registered Owner
Print Name of Registered Co-Owner
__________________________________________________________ ______________________________________________________________
Street Address (Owner)
Street Address (Co-Owner)
__________________________________________________________ ______________________________________________________________
City
State
Zip Code
City
State
Zip Code
3) APPLICATION FOR REASSIGNMENT OF LIEN
The undersigned hereby represents that they are the assignee of that certain
first or
second lien dated the _________________ day
of (Month/Year) __________________________, covering the motor vehicle, mobile home, off-highway vehicle or vessel described in section
one of this form and request that the Florida Certificate of Title, which was issued on (Month/Day/Year) ____________________________,
be re-issued to show such lien as now being held by the undersigned applicant and represents that on this date there is a balance as principal
still due and unpaid.
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING DOCUMENT AND THAT THE FACTS STATED IN IT ARE TRUE.
________________________________________________________ By __________________________________________________________
Name of Assignee (New Lienholder)
Signature of Lienholder's Representative
Title
_________________________________________________________
Address _________________________________________________ City _________________________ State _________ Zip Code __________
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING DOCUMENT AND THAT THE FACTS STATED IN IT ARE TRUE.
________________________________________________________ By __________________________________________________________
Name of Assignor (Lienholder currently shown on Title)
Signature of Lienholder's Representative
Title
_________________________________________________________
HSMV 82139 (Rev. 06/11) S
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