Form Hsmv 84491 - Additional Sheet To Statement Of Builder - Florida Department Of Highway Safety And Motor Vehicles

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STATE OF FLORIDA
DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES
STATEMENT OF BUILDER
(Additional Sheet)
REBUILT
ASPT
COMBINED
KIT CAR
OTHER:
SECTION I. Description of:
MOTOR VEHICLE
MOTORCYCLE
MOBILE HOME
1.
_________
_____________
_________________________ __________ ____________ ______________
Year
Make
Identification Number
Color
Body
Length
SECTION II. MAJOR COMPONENT PARTS USED IN THE BUILDING/REPAIR PROCESS
Please continue to list the major component parts used in the building/repair process.
2.
Part
New
Used
Repaired
After Market
Homemade
Source/VIN
__________
_______
_______ __________ ___________ ___________
_____________________________
__________
_______
_______ __________ ___________ ___________
_____________________________
__________
_______
_______ __________ ___________ ___________
_____________________________
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_______ __________ ___________ ___________
_____________________________
__________
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_______ __________ ___________ ___________
_____________________________
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_______ __________ ___________ ___________
_____________________________
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_______ __________ ___________ ___________
_____________________________
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_______ __________ ___________ ___________
_____________________________
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_______ __________ ___________ ___________
_____________________________
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_____________________________
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_____________________________
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_____________________________
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_____________________________
NOTE: Major component parts defined as: For motor vehicles other than motorcycles, any fender, hood, bumper, cowl assembly, rear quarter
panel, trunk lid, door, deck lid, floor pan, engine, frame, transmission, catalytic converter or airbag.
HSMV 84491 (Rev. 2/17)

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