Form Hsmv 87002 - Vessel Statement Of Builder
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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
VESSEL STATEMENT OF BUILDER
PART Ι. HOMEMADE VESSEL
____________________________________________
1.
I (We)
hereby certify that the vessel described in item 5
below was constructed or assembled by major components or materials purchased or obtained from the following sources:
HULL
DECK/RIGGING
MACHINERY/ENGINES
Attach copies of bill of sale or receipts (must contain name, address and signature of seller). Notarization is not required.
I
2.
(We) hereby certify that said vessel was built for my/our personal use. If other than for personal use, I (we) certify that
said vessel was constructed for the following individual or firm:
_____________________________________________________________________________________
Name
Street Address
_______________________________________________________________________________________________________________________________
City
State
Zip
3. I (We) hereby certify that all applicable sales tax has been paid on the material used in the construction of the vessel
described in item 5 below.
4.
I (We) hereby certify that the vessel described below has never been previously registered or titled with the State of
Florida, or in any other state or country, and that a Manufacturer’s Statement of Origin or Builder’s Certificate has never
been issued for said vessel.
5.
I (We) hereby certify that the following information applies to this specific vessel.
PRIMARY CONSTRUCTION SITE:
______________________________________________________
_________________________________
Street Address
City
_______________
_____________
_______________
______________
State:
Zip:
Year Vessel Construction Was Completed
Hull Length
VESSEL TYPE
HULL MATERIAL
PROPULSION
FUEL
Open Motorboat
Sailboat
Wood
Outboard
Gasoline
Cabin Motorboat
Airboat
Wood/Fiberglass
Inboard
Electric
Auxiliary Sailboat
Canoe
Fiberglass
Inboard/Outboard
Diesel
Inflatable
Pontoon
Aluminum
Air Propelled
Other _____________
Houseboat
Other __________
Steel
Sail
Specify
Personal Watercraft
Other _______________
Other _______________
Specify
Specify
Specify
PART Π. TO BE COMPLETED BY ALL APPLICANTS
DATE: ________________________
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING DOCUMENT AND THAT THE
FACTS STATED IN IT ARE TRUE. NO MATERIAL INFORMATION REGARDING THE VESSEL HAS BEEN OMITTED.
______________________________________________________________________________________________________
PRINTED NAME OF APPLICANT
PRINTED NAME OF CO-APPLICANT
_______________________________________________________________________________________________________________________________
STREET ADDRESS
STREET ADDRESS
_______________________________________________________________________________________________________________________________
CITY
STATE
ZIP
CITY
STATE
ZIP
TELEPHONE NUMBER: _________________________________________
TELEPHONE NUMBER: __________________________________
_______________________________________________________________________________________________________________________________
SIGNATURE OF APPLICANT
SIGNATURE OF CO-APPLICANT
HSMV 87002 (Rev.10/11)
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