Form Hsmv 82040 - Application For Certificate Of Title With/without Registration

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FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES
APPLICATION FOR CERTIFICATE OF TITLE WITH/WITHOUT REGISTRATION
SUBMIT THIS FORM TO YOUR LOCAL TAX COLLECTOR OFFICE
CHECK APPLICATION TYPE:
ORIGINAL
TRANSFER
VEHICLE TYPE:
MOTOR VEHICLE
MOBILE HOME
VESSEL
OFF-HIGHWAY VEHICLE:
ATV
ROV
MC
1
OWNER / APPLICANT INFORMATION
Customer Number
Check this box if you are requesting
Owner
Co-Owner
Unit Number
Fleet Number
the certificate of title to be printed.
Are you a Florida resident?
yes
no
yes
no
Are you an alien?
yes
no
yes
no
Iiiiiii
OR
AND NOTE: When joint ownership, please indicate if “or” or “and” is to be shown on title when issued. If neither box is checked, the title will be issued with "and."
If applicable:
Life Estate/Remainder Person
Tenancy By the Entirety
With Rights of Survivorship
Owner's County of Residence: _____________________________________
Owner’s Name As It Appears on Driver License (First, Full Middle/Maiden, & Last Name)
Owner’s Email Address
Date of Birth
Sex
FL Driver License or FEID/Suffix #
Co-Owner/Lessee’s Name As It Appears on Driver License (First, Full Middle/Maiden, & Last Name)
Co-Owner’s/Lessee’s Email Address
Date of Birth
Sex
FL Driver License or FEID/Suffix #
Owner’s Mailing Address (Mandatory unless a member of the Military)
City
State
Zip
Co-Owner’s/Lessee’s Mailing Address (Mandatory unless a member of the Military)
State
Zip
City
Owner’s/Lessee’s Physical Street Address in Florida (Mandatory unless a member of the Military)
State
Zip
City
Check if in a mobile home rental park with 10 or more lots.
Mobile Home Physical Address
(if applicable)
State
Zip
City
\\
Mail To Customer Name (If different From Above Owner)
Mail To Customer’s Email Address
Date of Birth
Sex
FL Driver License or FEID/Suffix #
Mail To Customer Address (If different From Above Mailing Address)
City
State
Zip
2
MOTOR VEHICLE , MOBILE HOME OR VESSEL DESCRIPTION
Vehicle/Vessel Identification Number
Make/Manufacturer
Year
Body
Color
Florida Title Number
License Plate or Vessel Registration Number
Previous State of Issue
Weight
Length
BHP/CC
GVW/LOC
VAN USE, IF APPLICABLE
Ft.
In.
PASSENGER
OTHER
TYPE
HULL MATERIAL
PROPULSION
FUEL
*DRAFT OF VESSEL
(The depth of water a
Open Motorboat
Houseboat
Personal Watercraft
Wood
Aluminum
Outboard
Sail
Gas
vessel draws)
Cabin Motorboat
Pontoon
Canoe
Fiberglass
Steel
Inboard
Air Propelled
Diesel
_________
Auxiliary Sailboat
Airboat
Other
Wood/Fiberglass
Inboard/Outboard
Electric
______
______
FT.
IN.
Inflatable
Sailboat
Other______________________
Other__________________________
Other_________________
Specify
*
For all vessels 26’ or more in
Specify
Specify
Specify
length and all sailboats
USE OF VESSEL
PREVIOUS
OUT-OF-STATE
Recreational (Pleasure)
Commercial Blue Crab
Commercial Stone Crab
Government
Commercial Sponge
REGISTRATION NUMBER:
Dealer/Manuf.
Commercial Fish
Commercial Live Bait
Commercial Shrimp Recip.
Commercial Charter
Commercial Other ______________
Exempt
Hire (Livery)
Commercial Mackerel
Commercial Shrimp Non-Recip.
Commercial Oyster
Commercial Spiney Lobster
Previously Federally Documented Vessel, Attach Copy of:
State of Principal Use
U.S. Coast Guard Release From Documentation Form; or
Copy of Canceled Documentation Papers
3
BRANDS, USAGE AND TYPE (Check Applicable Boxes)
SHORT TERM LEASE
LONG TERM LEASE
REBUILT
POLICE VEHICLE
PRIVATE USE
TAXI CAB
FLOOD
ILEV
CUSTOM
ASSEMBLED FROM PARTS
BONDED TITLE
KIT CAR
GLIDER KIT
MANUF. BUY BACK
REPLICA
AUTONOMOUS
ELECTRIC
STREET ROD
4
LIENHOLDER INFORMATION
Date of Lien
Lienholder's Name
CHECK
FEID #
DL # and Sex and Date of Birth
DMV Account #
IF ELT
CUSTOMER
Lienholder’s Email Address
Lienholder's Address
City
State
Zip
If Lienholder authorizes the Department to send the motor vehicle or mobile home title to the owner, check box and countersign: ________________________________________________________________________
(Does not apply to vessels). If box is not checked, title will be mailed to the first lienholder.
(Signature of Lienholder’s Representative)
5
TRANSFER TYPE
IF OWNERSHIP HAS TRANSFERRED, HOW AND WHEN WAS THE VEHICLE, MOBILE HOME, OR VESSEL ACQUIRED?
DATE ACQUIRED
SALE
GIFT
REPOSSESSION
COURT ORDER
OTHER (SPECIFY) __________________________________________
_________/___________/______________
6
ODOMETER DECLARATION
WARNING: Federal and State law requires that you state the mileage in connection with an application for a Certificate of Title. Failure to complete or providing a false statement may result in fines or imprisonment.
,
.
I/WE STATE THAT THIS
5 OR
6 DIGIT ODOMETER NOW READS
MILES, DATE READ _____ /_____ / ________ AND I/WE HEREBY CERTIFY
XX
(NO TENTHS)
THAT TO THE BEST OF MY/OUR KNOWLEDGE THE ODOMETER READING:
1. REFLECTS ACTUAL MILEAGE.
2. IS IN EXCESS OF ITS MECHANICAL LIMITS.
3. IS NOT THE ACTUAL MILEAGE.
DEALER SALES TAX REPORT AND VEHICLE TRADE IN INFORMATION (IF APPLICABLE)
7
FLORIDA SALES TAX REGISTRATION NUMBER
DATE OF SALE
DEALER LICENSE NUMBER
AMOUNT OF TAX
DEALER / AGENT SIGNATURE
YEAR OF TRADE IN
MAKE OF TRADE IN
TITLE NUMBER OF TRADE IN (IF KNOWN)
VEHICLE IDENTIFICATION NUMBER OF TRADE IN
HSMV 82040 – REV. 12/12

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