Form Hsmv 82101 - Application For Duplicate Or Lost In Transit - 2009

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STATE OF FLORIDA

DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES

DIVISION OF MOTOR VEHICLES

2900 Apalachee Parkway, MS# 72,

Neil Kirkman Building - Tallahassee, FL 32399

APPLICATION FOR DUPLICATE OR LOST IN TRANSIT/REASSIGNMENT FOR A

MOTOR VEHICLE, MOBILE HOME OR VESSEL TITLE CERTIFICATE

TYPE OF APPLICATION

VEHICLE/VESSEL DUPLICATE:

VEHICLE/VESSEL LOST IN TRANSIT:

VEHICLE/VESSEL DUPLICATE WITH TRANSFER:

(Fee Required)

(Both parties must be present for this transaction)

NOTE: No fee required if vehicle application

is made within 180 days from last title

LOST

STOLEN

AND NOTE: When joint ownership, please indicate if “or” or “and”

issuance date and has been lost in mailing.

is to be shown on the title when issued. If neither box is checked, the title

Damaged

(Certificate of Title must be submitted)

will be issued with “and”.

NOTE: An indication of lost, stolen or damaged is required

OWNER’S NAME

Owner’s E-Mail Address

PURCHASER’S NAME

Purchaser’s E-Mail Address

(Last, First, Middle Initial)

CO-OWNER’S NAME

(Last, First, Middle Initial)

Co-Owner’s E-Mail Address

CO-PURCHASER’S NAME

(Last, First, Middle Initial)

Co-Purchaser’s E-Mail Address

OWNER’S MAILING ADDRESS

PURCHASER’S MAILING ADDRESS

CITY

STATE

ZIP

CITY

STATE

ZIP

CAUTION: IF ADDRESS DIFFERS FROM DMV RECORDS, ADDRESS VERIFICATION

DATE OF BIRTH

PURCHASER’S DL/ID #

CO-PURCHASER’S DL/ID#

MUST BE SUBMITTED

APPLICATION FOR DUPLICATE IS MADE BY:

MOTOR VEHICLE, MOBILE HOME OR RECREATIONAL VEHICLE DEALER/

LIENHOLDER DATE OF LIEN

AUCTION LICENSE NUMBER

________________________

(DEALER/AUCTION LICENSE NUMBER DOES NOT APPLY TO VESSELS)

OWNER

LIENHOLDER OR DEALER/AUCTION NAME:

________________________________________________________________________

__________________________________

ADDRESS ______________________________________

CITY _________________________

STATE _______

ZIP _____________

MOTOR VEHICLE, MOBILE HOME OR VESSEL DESCRIPTION

Vehicle/Vessel Identification Number

Make/Manufacturer

Year

Body

Color

License Plate or Vessel Registration Number

Florida Title Number

VEHICLE USAGE/BRANDS

SHORT TERM LEASE

LONG TERM LEASE

POLICE VEHICLE

PRIVATE USE

TAXI CAB

FLOOD VEHICLE

REPLICA

KIT CAR

GLIDER KIT

REBUILT

ASSEMBLED FROM PARTS

MANUFACTURER’S BUY BACK

LIENHOLDER INFORMATION

If no lien, Print “None”

FEID #

DL# & Sex and Date of Birth

DMV Account #

Date of Lien

Lienholder Name

Lienholder E-Mail Address

Lienholder Mailing Address

City

State

Zip

If Lienholder authorizes the Department to send title to the owner, check box and countersign.

(Signature of Lienholders Representative)

If this box is not checked, title will be mailed to the first lienholder.

(DOES NOT APPLY TO VESSELS)

APPLICATION ATTESTMENT/SIGNATURES AND ODOMETER DECLARATION/DISCLOSURE

WARNING: Federal and state law require that you state the mileage in connection with an application for Certificate of Title. Providing a false statement may result in fines or imprisonment.

I (WE) STATE THAT THIS

5 or

6 DIGIT ODOMETER NOWS READS

.XX (NO TENTHS) MILES,

DATE READ ________/_______/________, AND I/WE HEREBY CERTIFY THAT TO THE BEST OF MY/OUR KNOWLEDGE THE ODOMETER READING:

CAUTION: READ CAREFULLY BEFORE YOU CHECK A BOX

1. REFLECTS ACTUAL MILEAGE.

2. IS IN EXCESS OF ITS MECHANICAL LIMITS. (EXCESS OF ITS MECHANICAL LIMITS APPLIES TO 5 DIGIT ODOMETERS)

3. IS NOT THE ACTUAL MILEAGE. WARNING - ODOMETER DISCREPANCY

I CERTIFY THAT THE MOTOR VEHICLE/VESSEL DESCRIBED ABOVE WILL NOT BE OPERATED ON THE STREETS AND HIGHWAYS/WATERWAYS OF THIS STATE

AND NO FLORIDA LICENSE PLATE HAS BEEN TRANSFERRED TO OR PURCHASED FOR THIS MOTOR VEHICLE.

I am/we are the owner(s), lienholder(s), and am legally authorized to apply for and receive the Duplicate Certificate of Title. I/we further agree to indemnify the

Department and defend the Certificate of Title against all actions or claims by any person.

UNDER PENALTIES OF PERJURY, I/WE DECLARE THAT I/WE HAVE READ THE FOREGOING DOCUMENT AND THAT THE FACTS STATED IN IT ARE TRUE.

Date Sold

Selling Price $

IF APPLICABLE, I ATTEST TO HAVING

ACQUIRED THE MOTOR VEHICLE, MOBILE

PURCHASE

GIFT

INHERITANCE

COURT ORDER

HOME OR VESSEL DESCRIBED ABOVE BY:

Signature of