Form Hsmv 84058 - Vehicle Air Pollution Control Statement

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Vehicle Air Pollution Control Statement
Florida Law prohibits the operation, sale, lease, or transfer of title of any automobile or light-duty truck
(1975 or newer, 10,000 pounds gross vehicle weight or less) that has been tampered with. "Tampering"
means the dismantling, removal, or rendering ineffective of any air pollution control device or system
which has been installed on the vehicle by the vehicle manufacturer except to replace such device or
system with a device or system equivalent in design and function to the part that was originally installed
on the motor vehicle (316.2935, Florida Statutes).
As a motor vehicle dealer licensed to conduct business in the State of Florida, I hereby certify that the
following air pollution emission control devices and system of this vehicle, if installed by the vehicle
manufacturer or importer, have not been tampered with by me or by my agents, employees, or other
representatives. I also hereby certify that I or persons under my supervision have inspected this motor
vehicle and, based on said inspection, have determined that the air pollution control devices and systems
listed below, if installed by the vehicle manufacturer or importer, are in place and appear properly
connected and undamaged as determined by visual observation.
This certification shall not be deemed or construed as a warranty that any air pollution control device or
system of the vehicle is in functional condition, nor does the execution or delivery of this certification
create by itself grounds for a cause of action between the parties to this transaction.
MAKE:
MODEL:
BODY TYPE:
VIN:
YEAR:
Transferor's (Seller's) Signature: __________________________________________________________
Transferor's (Seller's) Printed Name: ______________________________________________________
Transferor's (Seller's) Street Address: ______________________________________________________
City: __________________________ State: ________________ Zip Code: _____________________
Date of Statement: _____________________________________________________________________
Transferee's (Buyer's) Signature: _________________________________________________________
Transferee's (Buyer's) Printed Name: ______________________________________________________
Transferee's (Buyer's) Street Address: _____________________________________________________
City: __________________________ State: ________________ Zip Code: _____________________
1975 – 1980 Model Year:
1981 or Newer Model Year
Catalytic Converter
Catalytic Converter
Fuel Inlet Restrictor
Fuel Inlet Restrictor
Unvented Fuel Cap
Unvented Fuel Cap
Exhaust Gas Recirculation System (EGR)
Air Pump and/or Air Injection System (AIS)
Fuel Evaporative Emissions System (EVP)
_______________________________________
Stock No.
Form approved by the Department of Environmental Protection
HSMV 84058 (06/10)

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