DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES
DIVISION OF MOTORIST SERVICES
SUBMIT THIS FORM TO YOUR LOCAL TAX COLLECTOR OFFICE
VEHICLE IDENTIFICATION NUMBER AND ODOMETER VERIFICATION
PART A - OWNER’S VEHICLE IDENTIFICATION AFFIDAVIT AND ODOMETER DECLARATION
(Completion of this part requires a physical inspection of the vehicle by the owner)
This is to certify that I, the undersigned, am the lawful owner of the motor vehicle described on this form and that I have,
on the date entered above, made a physical inspection of the motor vehicle and have recorded the vehicle identification
number and other identification information and the odometer reading and certification in the spaces provided on this form.
(MOTOR NUMBER ALL MAKES THROUGH 1954 - IDENTIFICATION NUMBER 1955 AND LATER)
Previous State Vehicle Titled In
Vehicle Identification Number
WARNING: Federal and State law require 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 and/or imprisonment.
I /WE STATE THAT THIS
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:
. reflects ACTUAL MILEAGE.
. is IN EXCESS OF ITS MECHANICAL LIMITS.
. is NOT THE ACTUAL MILEAGE.
UNDER PENALTY OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING
DOCUMENT AND THAT THE FACTS STATED IN IT ARE TRUE.
(Owner’s Printed Name)
PART B – VERIFICATION OF THE VEHICLE IDENTIFICATION NUMBER
This section requires a physical inspection and a verification of the vehicle identification number (VIN) (or the motor number for motor
vehicles manufactured prior to 1955) of the motor vehicle described on this form by a Florida Notary Public, Licensed Dealer, Police
Officer, or Florida Division of Motorist Services Employee or Tax Collector Employee. If an out-of-state motor vehicle dealer verifies the
VIN, the verification must be submitted on their letterhead stationery. Complete this section on all used motor vehicles, including trailers,
(with abbreviation of “TL” with a weight of 2,000 pounds or more) not currently titled in Florida.
I, the undersigned, certify that I have physically inspected the above described vehicle and find that the vehicle identification number on
the vehicle to be identical to the vehicle identification number recorded on this form.
_______________________________ Notary’s Signature: ________________________________
Commissioned Name of Florida Notary:
(Print, Type or Stamp)
UNDER PENALTY OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING DOCUMENT AND THAT THE FACTS
STATED IN IT ARE TRUE.
If other than a Notary, check the box below that applies and sign and complete the corresponding fields. Verified by:
Florida Compliance Examiner/Inspector(DMS/TC Employee)
Law Enforcement Officer
Florida Licensed Dealer
Signature: ______________________________________ Printed Name: ______________________________________________
Florida Compliance Examiner/Inspector Name:
__ Badge or ID #:
Law Enforcement Agency Name:
LEO Badge #:
Florida Dealer Name:
Florida Dealer #: _______________________________
NOTICE: ANY ALTERATION OR ERASURE MAY VOID THIS DOCUMENT
HSMV 82042 (REV. 01/13)