Form Hsmv 82012 - Application For Towing And Storage Certificate Of Destruction
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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 TOWING AND STORAGE CERTIFICATE OF DESTRUCTION
1
OWNER / APPLICANT IDENTIFICATION
Owner’s Name (Tow/Transport Company)
FEID Number
Email Address
Tow Company's Street Address
City
State
Zip
2
VEHICLE/VESSEL DESCRIPTION
Vehicle/Vessel/Mobile Home Identification Number
Year
Make
Color
Body
Weight
Previous State of Issue
Length (if applicable)
BHP/CC (if applicable)
Florida Title Number or FL#
3
TYPE OF TOW
PUBLIC
PRIVATE
4
OWNER / APPLICANT’S CERTIFICATIONS
The Motor Vehicle/Vessel/Mobile Home described above was owned by ________________________________________________,
(Last Registered Owner of Record)
with a recorded lien to ___________________________________________________________________ and has been lawfully sold to
(Registered Lienholder of Record)
__________________________________________________ on ___________________, in a Non-Judicial State for enforcement
(Towing/Transport Company)
(Date)
of a lien for towing and storage charges justly owing and unpaid since _____________________. Having followed all provisions of
(Impound Date)
Section 713.78 or 713.785, Florida Statutes, I understand that no sales tax is due and I certify that the vehicle/vessel/mobile home
identification number shown on this application has been physically inspected by me, and is identical to the vehicle/vessel/mobile home
identification number shown on the motor vehicle/vessel/mobile home.
I have made a diligent search and inquiry as to the registered owner, lienholder and insurance company without beneficial results.
A good faith effort has been made as defined in Section 713.78 or 713.785, Florida Statutes.
I hereby certify that ownership information was unavailable within the seven (7) day period required by law and hereby certify that law
enforcement was notified by this company after seven (7) days. Attached is a copy of the notice sent to law enforcement and a copy
of the returned receipt showing the date or a copy of the acknowledged hand-delivered receipt signed by the law enforcement
agency.
I hereby certify that the owner of the motor vehicle/vessel/mobile home described above has transferred the attached title over to our
tow/transport company in lieu of paying the towing and storage charges. We understand this process will permanently relinquish our
company's ability to place a wrecker operator's lien against the owner of this vehicle/vessel/mobile home.
If applying for a "duplicate" Certificate of Destruction, check this block:
I hereby certify that this company is the owner of the motor vehicle/vessel/mobile home described above and a Certificate of
Destruction was issued in the company's name on ________________. I hereby certify that the Certificate of Destruction has been
lost or destroyed and request a duplicate Certificate of Destruction be issued. If the lost or missing Certificate of Destruction is located,
it will be returned to the Department.
5
MOTOR VEHICLE ODOMETER DECLARATION
,
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 KNOWLEDGE THE ODOMETER READING IS:
1. reflects ACTUAL MILEAGE.
2. is IN EXCESS OF ITS MECHANICAL LIMITS.
3. is NOT THE ACTUAL MILEAGE.
WARNING – ODOMETER DISCREPANCY
6
OWNER / APPLICANT’S SIGNATURE
In consideration of the foregoing and the attached evidence of ownership to the motor vehicle/vessel/mobile home described above, I
request that the Certificate of Destruction be issued in the towing/transport company's name.
I hereby swear or affirm, under penalty of perjury, that this company owns the above-described motor vehicle/vessel/mobile home and I
affirm under penalty of perjury that all of the foregoing information is true and correct. I further agree to defend the title against all claims. I
further certify that I have made a physical inspection of the vehicle (when applicable) and have recorded the vehicle identification number,
other identification information and the odometer reading in the spaces provided on this form.
Name of Tow/Transport Company _____________________________________________________________________________
Signature of Agent _____________________________ Printed Name of Agent: _________________________________________
HSMV 82012 (Rev. 06/13) S
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