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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

1 VEHICLE/VESSEL DUPLICATE:

(Fee Required)

LOST

STOLEN

TYPE OF APPLICATION

VEHICLE/VESSEL LOST IN TRANSIT:

NOTE: No fee required if vehicle application is made within 180 days from last title

VEHICLE/VESSEL DUPLICATE WITH TRANSFER: (Both parties must be present for this transaction)

OR

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

Damaged (Certificate of Title must be submitted)

issuance date and has been lost in mailing.

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

is to be shown on the title when issued. If neither box is checked, the title will be issued with “and”.

OWNER’S NAME (Last, First, Middle Initial)

Owner’s E-Mail Address

PURCHASER’S NAME (Last, First, Middle Initial)

Purchaser’s E-Mail Address

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 MUST BE SUBMITTED

DATE OF BIRTH

PURCHASER’S DL/ID #

CO-PURCHASER’S DL/ID#

2

APPLICATION FOR DUPLICATE IS MADE BY:

LIENHOLDER DATE OF LIEN

MOTOR VEHICLE, MOBILE HOME OR RECREATIONAL VEHICLE DEALER/ AUCTION LICENSE NUMBER (DEALER/AUCTION LICENSE NUMBER DOES NOT APPLY TO VESSELS)

________________________

OWNER

LIENHOLDER OR DEALER/AUCTION NAME:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

__________________________________

ADDRESS

CITY

STATE

ZIP

______________________________________

_________________________

_______

_____________

3

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

4

VEHICLE USAGE/BRANDS

SHORT TERM LEASE REPLICA

LONG TERM LEASE

KIT CAR

GLIDER KIT

POLICE VEHICLE REBUILT

PRIVATE USE

TAXI CAB

ASSEMBLED FROM PARTS

FLOOD VEHICLE MANUFACTURER’S BUY BACK

5

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.

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

(DOES NOT APPLY TO VESSELS)

(Signature of Lienholders Representative)

6

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.

IF APPLICABLE, I ATTEST TO HAVING ACQUIRED THE MOTOR VEHICLE, MOBILE HOME OR VESSEL DESCRIBED ABOVE BY:

PURCHASE

GIFT

INHERITANCE

COURT ORDER

Date Sold

Selling Price $

Signature of Purchaser:

_______________________________________________________________________

Printed Name o f P u r c h a s e r : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Signature of Co-Purchaser:

Printed Name of Co-Purchaser’s:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

______________________________________________________________________

Signature of Seller/ Owner/Lienholder:

Printed Name of

Seller/ Owner/Lienholder:

__________________________________________________________________

______________________________________________________________

Signature of

Co-Owner:

________________________________________________________________________

Printed Name of Co-Owner: __________________________________________________________________________

7

FOR FLORIDA DMV OR TAX COLLECTOR/LICENSE PLATE AGENCY USE ONLY

Duplicate authorization verification completed

Signature

Printed Name

County

Agency #

Date Completed

HSMV 82101 (Rev.07/09) S

www.flhsmv.gov

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