The State of Florida created this State Constitutional County Office as
a separate and independent government entity to ensure freedom from influence
by local or state agencies that have the power to levy taxes, spend tax dollars and assess property.
BEN ANDERSON
OKALOOSA COUNTY TAX COLLECTOR
Customer Service Processing Center
701 E. John Sims Pkwy, Suite 202
Niceville, FL 32578
www.OkaloosaTax.com
(850) 651-7300
Name (s)_______________________________________________________________________
Address: ________________________________City________________State_____Zip________
Phone (Home)_________________(Cell)__________________Email_______________________
Vessel Information:
Vessel Year:________Make:_______________Hull #____________________________________
Trailer Information
Trailer Year: ________Make: _______________TIN#____________________________________
Please read this thoroughly and follow all directions in order to expedite the title and registration
process. Submit the following documents:
1. Original Vessel Title or MCO (Manufacturer Certificate of Origin)
• MCO – Newly purchased vessels that have never been titled or registered.
• Out of state title – If this is a newly acquired vessel, the “Transfer of Title by Seller”
section on the certificate of title must be completed in full with printed name(s) and
signature(s) for each transferor (seller) and each transferee (purchaser).
• Bill of sale – If purchased from a dealership.
• If vessel has been registered in a non-titling state, the current registration will
substitute for a title. The most current record we have of non-titling states are:
Alabama, Alaska, Arizona, Arkansas, Colorado, Connecticut, Delaware, Georgia,
Hawaii, Kansas, Louisiana, Maine, New Hampshire, North Dakota and Tennessee.
When transferring ownership with a registration, an original bill of sale must
accompany the registration.
2. Lien Holder Letter
An owner who is making payments on their vessel may not hold the title in their possession.
If a lending or financial institution holds the title to the vessel, complete the enclosed Lien
Holder Letter. Fax the letter to your lien holder. This letter informs the lien holder the
necessity of forwarding the title to our office. When a lien holder has a claim on a vessel, we
cannot make any changes to the owner section without written authorization from the lien
holder
The State of Florida created this State Constitutional County Office as
a separate and independent government entity to ensure freedom from influence
by local or state agencies that have the power to levy taxes, spend tax dollars and assess property.
3. Form HSMV 82040, Application for Certificate of Title
Fill form out in its entirety. Refer to completed Example form in packet.
If you do not have a Florida Driver License, you must submit a copy of your out of state
driver license.
4. Sales Tax
Sales tax is calculated at 6% plus the discretionary sales surtax tax of 1% on the first
$5,000.00 of the purchase price less any trade in value. If the state you purchased or titled the
vessel in has collected sales tax, that tax will be credited towards Florida sales tax. Proof of
the tax paid will be required. If the vehicle has been titled in your name longer than six
months, sales tax will not be required.
5. Trailers
If a trailer has a net weight of 1,999 pounds or less, it is not required to be titled. The
following would be required to register the trailer.
• When the trailer is new, a copy of the MCO and/or bill of sale showing a complete
chain of ownership.
• Proof of ownership – title, registration or bill of sale with complete vessel description
(year, make and trailer identification number).
• When the trailer is used (homemade or manufactured) and never been registered in
Florida, a certified weight slip is required, unless the documentation submitted shows
a net weight.
6. Fees
Refer to fee chart included. Return fee chart with your completed paperwork.
7 Form of payment
• Check – Made payable to Okaloosa County Tax Collector
• Credit/Debit Card – We accept MasterCard, Discover and American Express (Bank Card User
Fees will be added). For your privacy and security reasons, credit/debit card information
cannot be included on this paperwork. Our office will contact you at the time of processing.
Name________________________ Daytime Phone number_________________________
E-mail address______________________________________________________________
• E-check (Personal Checks ONLY)- I give OCTC permission to process my payment as an E-
check (Must provide a voided check or image thereof) Please contact me if the total exceeds:
$______________. Please sign here: ____________________________________________
Our Customer Service and Processing Center is available to answer questions Monday to Friday from
8:30a.m. through 5:00p.m. CST. The toll free number is 1-877-TAGSRUS (824-7787) or
850-651-7300. You can also contact our office via email at cspcweb@OkaloosaTax.com.
Our Mailing Address is:
Okaloosa County Tax Collector
Attn: Customer Service and Processing Center
701 E. John Sims Pkwy, Suite 202
Niceville, FL 32578
Lienholder Name:
Account Number:
Applicant(s) Names:
Address:
City:
State:
Zip:
E-mail Address:
Telephone Number(s):
Home:
Cell:
Vehicle Description:
Year:
Make:
VIN:HIN
The above named individual(s) desire to title and register their vehicle/vessel in the state of Florida. We
require that one of the following options be complied with in order to title and register in Florida. If customer’s
name has changed due to marriage, divorce, court order, etc., in order to title in Florida, it is necessary that
we title in the lawful name at the time of application. Please return this letter with your reply.
Florida's Electronic Lien and Title (ELT) program requires mandatory participation from
lenders
. As of January 1, 2013 and thereafter, businesses and individuals who regularly engage in the
business or practice of financing vehicles or vessels, are required to be ELT participants. For more
information please visit http://www3.flhsmv.gov/DMV/Proc/TL/TL-69.pdf
Enter here if you already have a FL ELT Account Number_________________________________
Lienholder Will Surrender Title
Submit the original title to our office along with this request. Your existing lien will be recorded on
the Florida Electronic Title.
Lienholder Federal Identification Number ___________________________________
Lienholder Will Not Surrender Title
If it is your company’s policy not to surrender a title for registration and titling in another state, you do not
authorize the name change, or you do not participate in Florida’s ELT program please indicate such on
company letterhead and include applicant(s) name and a full description of the vehicle. Please send the
letter of refusal, a copy of the title, and this request.
P
lease mail all correspondence to the following address:
O
kaloosa County Tax Collector
701 E. John Sims Pkwy Ste 202 ATTN: CSPC Niceville, FL 32578
I
f you have any questions regarding this request, please call:(850) 651-7300.
11/12/2020
OKALOOSA COUNTY TAX COLLECTOR
www.OkaloosaTax.com
701 E. John Sims Pkwy, Suite 202 Niceville, FL 32578
Lien Holder Letter
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
www.flhsmv.gov/offices/
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
the certificate of title to be printed.
Owner Co-Owner
Are you a Florida resident? yes no yes no
Are you an alien? yes no yes no
Unit Number
Fleet Number
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 A
ppears 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)
City
State
Zip
Owner’s/Lessee’s Physical Street Address in Florida (Mandatory unless a member of the Military)
City
State
Zip
Mobile Home Physical Address (if applicable)
Check if in a mobile home rental park with 10 or more lots.
\\
City
State
Zip
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
Previous State of Issue
License Plate or Vessel Registration Number
Weight
Length
Ft. In.
BHP/CC
GVW/LOC
VAN USE, IF APPLICABLE
PASSENGER OTHER
TYPE
Open Motorboat Houseboat Personal Watercraft
Cabin Motorboat Pontoon Canoe
Auxiliary Sailboat Airboat Other _________
Inflatable Sailboat Specify
HULL MATERIAL
Wood Aluminum
Fiberglass Steel
Wood/Fiberglass
Other______________________
Specify
PROPULSION
Outboard Sail
Inboard Air Propelled
Inboard/Outboard
Other__________________________
Specify
FUEL
Gas
Diesel
Electric
Other_________________
Specify
*DRAFT OF VESSEL
(The depth of water a
vessel draws)
FT. ______ IN. ______
*For all vessels 26’ or more in
length and all sailboats
USE OF VESSEL
Recreational (Pleasure) Commercial Blue Crab Commercial Stone Crab Government Commercial Sponge
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
PREVIOUS
OUT-OF-STATE
REGISTRATION NUMBER:
Previously Federally Documented Vessel, Attach Copy of:
U.S. Coast Guard Release From Documentation Form; or Copy of Canceled Documentation Papers
State of Principal Use
3
BRANDS, USAGE AND TYPE (Check Applicable Boxes)
SHORT TERM LEASE
ASSEMBLED FROM PARTS
LONG TERM LEASE
BONDED TITLE
REBUILT
KIT CAR
POLICE VEHICLE
GLIDER KIT
PRIVATE USE
MANUF. BUY BACK
TAXI CAB
REPLICA
FLOOD
AUTONOMOUS
ILEV
ELECTRIC
CUSTOM
STREET ROD
4
LIENHOLDER INFORMATION
CHECK
IF ELT
CUSTOMER
FEID # DL # and Sex and Date of Birth DMV Account #
Date of Lien
Lienholder's Name
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?
SALE GIFT REPOSSESSION COURT ORDER OTHER (SPECIFY) __________________________________________ DATE ACQUIRED _________/___________/______________
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 , .XX (NO TENTHS) MILES, DATE READ _____ /_____ / ________ AND I/WE HEREBY CERTIFY
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.
7
DEALER SALES TAX REPORT AND VEHICLE TRADE IN INFORMATION (IF APPLICABLE)
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
www.flhsmv.gov
HSMV 82040 – REV. 11/15 RULE
15C-21.001, FAC
8
MOTOR VEHICLE IDENTIFICATION NUMBER VERIFICATION
T
HIS 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 LICENSED DEALER, FLORIDA NOTARY PUBLIC, POLICE OFFICER, OR FLORIDA DIVISION OF MOTOR VEHICLES
EMPLOYEE OR TAX COLLECTOR EMPLOYEE. IF THE VIN IS VERIFIED BY AN OUT OF STATE MOTOR VEHICLE DEALER, THE VERIFICATION MUST BE SUBMITTED ON THEIR LETTERHEAD
S
TATIONERY. 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
T
ITLED IN FLORIDA.
I, the undersigned, certify that I have physically inspected the above described vehicle and find the vehicle identification number to be:
(Vehicle Identification Number)
__________________________________ ___________________________________________________________________________ _____________________________________________________________________________________________
DATE SIGNATURE PRINTED NAME
Law Enforcement Officer or Florida Dealer/Agency Name _______________________________________________________ Badge # or Florida Dealer # ______________________ Notary Stamp or Seal
FL DMV/Tax Collector Employee
______________________________________________ Florida Compliance Examiner/Inspector Badge or ID Number___________________________
C
OMMISSIONED NAME OF FLORIDA NOTARY: __________________________________________________ NOTARY'S SIGNATURE _________________________________________________
(Print, Type or Stamp)
9
SALES TAX EXEMPTION CERTIFICATION
T
HE PURCHASE OF A RECREATIONAL VEHICLE TO BE OFFERED FOR RENT AS LIVING ACCOMMODATIONS DOES NOT QUALIFY FOR EXEMPTION. I CERTIFY THE RECREATIONAL VEHICLE, MOBILE HOME OR VESSEL DESCRIBED HAS
BEEN PURCHASED AND IS EXEMPT FROM THE SALES TAX IMPOSED BY CHAPTER 212, FLORIDA STATUTES, BY:
PURCHASER (STATE AGENCIES, COUNTIES, ETC.) HOLDS VALID EXEMPTION CERTIFICATE
CONSUMER’S CERTIFICATE OF EXEMPTION NUMBER
MOTOR VEHICLE MOBILE HOME VESSEL WILL BE USED EXCLUSIVELY FOR RENTAL
SALES TAX REGISTRATION NUMBER
I hereby certify that ownership of the motor vehicle, mobile home or vessel described on this application, is not subject to Florida Sales and Use Tax for the following reason: INHERITANCE GIFT
DIVORCE DECREE TRANSFER BETWEEN A MARRIED COUPLE EVEN TRADE OR TRADE DOWN (State the facts of the even trade or trade down and the transferor information, including
the transferor's name and address, below under "Other: Explain.")
OTHER: (EXPLAIN)
1
0
REPOSSESSION DECLARATION
IF CHECKED, THE FOLLOWING CERTIFICATIONS ARE MADE BY THE APPLICANT:
I CERTIFY THAT THIS MOTOR VEHICLE, MOBILE HOME OR VESSEL WAS REPOSSESSED UPON DEFAULT IN THE TERMS OF THE LIEN INSTRUMENT AND IS NOW IN MY POSSESSION.
(VESSEL) A PHOTOCOPY OF THE LIEN INSTRUMENT FOR THE VESSEL IS REQUIRED AND ATTACHED.
I AM REQUESTING THAT AN ORIGINAL CERTIFICATE OF REPOSSESSION BE ISSUED FOR THE MOTOR VEHICLE OR MOBILE HOME IN LIEU OF A TITLE (REPOSSESSION).
I AM REQUESTING THAT A DUPLICATE CERTIFICATE OF REPOSSESSION BE ISSUED FOR THE MOTOR VEHICLE OR MOBILE HOME, AS THE ORIGINAL HAS BEEN LOST OR DESTROYED.
11
NON-USE AND OTHER CERTIFICATIONS
IF CHECKED, THE FOLLOWING CERTIFICATIONS ARE MADE BY THE APPLICANT:
I CERTIFY THAT THE CERTIFICATE OF TITLE IS LOST OR DESTROYED.
THE VEHICLE IDENTIFIED WILL NOT BE OPERATED ON THE STREETS AND HIGHWAYS OF THIS STATE UNTIL PROPERLY REGISTERED.
THE VESSEL IDENTIFIED WILL NOT BE OPERATED ON THE WATERS OF THIS STATE UNTIL PROPERLY REGISTERED.
OTHER: (EXPLAIN) _________________________________________________________________________________________________________________________________________________________
12
A
PPLICATION ATTESTMENT AND SIGNATURES
I/WE PHYSICALLY INSPECTED THE ODOMETER/VIN AND FURTHER AGREE TO DEFEND THE TITLE AGAINST ALL CLAIMS. (More than one form HSMV 82040 may be used for additional signatures.)
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING DOCUMENT AND THAT THE FACTS STATED IN IT ARE TRUE.
_________________________________________________________________________________________________ _________________________________________________________________________________________________
SIGNATURE OF APPLICANT (OWNER) Date SIGNATURE OF APPLICANT (CO-OWNER) Date
1
3
RELEASE OF SPOUSE OR HEIRS INTEREST
The undersigned person(s) state(s) as follows: That
_________________________________________________________________________ died on _____________________________.
(Name of Deceased) (Date)
testate (with a will) intestate (without a will) and left the surviving heir(s) named below.
When applicable, the heir(s) (named below) certifies that the certificate of title is lost or destroyed.
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING DOCUMENT AND THAT THE FACTS STATED IN IT ARE TRUE.
(More than one form HSMV 82040 may be used for additional signatures.)
Print or Type Name of Spouse, Co-owner or Heir(s) Signature of Spouse, Co-Owner or Heir(s)
________________________________________________________________________________ ________________________________________________________________________________
________________________________________________________________________________ ________________________________________________________________________________
________________________________________________________________________________ ________________________________________________________________________________
That at the time of death the decedent was owner of the motor vehicle, mobile home or vessel described in section 2 of this form. The person(s) signing above hereby releases all of his/her/their right, title, interest and claim as
heir(s) at law, legatee(s), devisee(s), or otherwise to the aforesaid motor vehicle, mobile home or vessel to:
RESIDENTS OF FLORIDA AND ALL VESSEL OWNERS, RESIDING IN FLORIDA OR OUT OF STATE, SHOULD SUBMIT THIS FORM A
ND ALL REQUIRED DOCUMENTATION TO
A LOCAL FLORIDA TAX COLLECTOR’S OFFICE OR THE FLORIDA TAX COLLECTOR'S OFFICE LOCATED IN THE APPLICANT'S COUNTY OF RESIDENCE FOR
PROCESSING.
Check your local phone book government pages or visit the following website for current mailing addresses: http://www.flhsmv.gov/offices/
www.flhsmv.gov
HSMV 82040 – REV. 11/15
Name of Applicant(s) (Print or Type)
RULE 15C-21.001, FAC
S
IS
*
(
)
Itemized Bill of Sale for Vessel and/or Trailer
I, on the day of , 20 do hereby sell to:
for the sum of $ .
Description for vessel as follows:
Year:
Hull Id:
Make:
Title #:
Length:
Ft In Registration State:
Description for trailer as follows: (or copy of registration)
Year:
VIN:
Itemized amount paid for boat, motor, and trailer:
Boat: $
Outboard Motor: $
Trailer: $
Under penalties of perjury, I declare that I have read the foregoing document and that
the facts stated in it are true.
Signature of Seller
Per Florida Statue #327.12.01 & 02 Page 970
Notice to purchaser: This bill of sale when kept aboard the vessel when in use serves as
temporary authority to use the vessel on the waters of this state and is invalid after 30
days from the date of sale shown at the top of the bill of sale, as long as the vessel is used
as recreational and not commercial purposes.
Signature of Purchaser
Street address
City, State, Zip code
Trailer Registration Fee Cha
rt
Amount of Months Until Upcoming Birthday
Weight 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
550 $17.10 $17.10 $17.10 $17.10 $17.10 $17.10 $17.65 $18.44 $19.24 $20.01 $20.82 $21.60 $22.40 $26.49 $27.29 $36.86 $37.67 $38.45
650 $17.10 $17.10 $17.10 $17.10 $17.10 $17.36 $18.22 $19.11 $19.98 $20.85 $21.72 $22.60 $23.48 $27.66 $28.53 $38.19 $39.08 $39.96
750 $17.10 $17.10 $17.10 $17.10 $17.10 $17.85 $18.81 $19.77 $20.73 $21.68 $22.64 $23.60 $24.56 $28.82 $29.78 $39.53 $40.49 $41.45
850 $17.10 $17.10 $17.10 $17.10 $17.31 $18.36 $19.39 $20.44 $21.48 $22.52 $23.56 $24.60 $25.64 $30.00 $31.03 $40.86 $41.91 $42.96
950 $17.10 $17.10 $17.10 $17.10 $17.73 $18.85 $19.98 $21.11 $22.24 $23.34 $24.48 $25.60 $26.73 $31.16 $32.29 $42.19 $43.33 $44.45
1050 $17.10 $17.10 $17.10 $17.10 $18.15 $19.36 $20.55 $21.77 $22.98 $24.18 $25.39 $26.60 $27.81 $32.33 $33.53 $43.53 $44.75 $45.96
1150 $17.10 $17.10 $17.10 $17.10 $18.56 $19.85 $21.14 $22.44 $23.73 $25.01 $26.31 $27.60 $28.89 $33.49 $34.78 $44.86 $46.16 $47.45
1250 $17.10 $17.10 $17.10 $17.10 $18.97 $20.36 $21.73 $23.11 $24.48 $25.85 $27.23 $28.60 $29.97 $34.66 $36.03 $46.19 $47.57 $48.96
1350 $17.10 $17.10 $17.10 $17.10 $19.40 $20.85 $22.31 $23.77 $25.24 $26.68 $28.14 $29.60 $31.06 $35.82 $37.29 $47.53 $49.00 $50.45
1450 $17.10 $17.10 $17.10 $17.10 $19.81 $21.36 $22.89 $24.44 $25.98 $27.52 $29.06 $30.60 $32.14 $37.00 $38.53 $48.86 $50.41 $51.96
1550 $17.10 $17.10 $17.10 $17.10 $20.23 $21.85 $23.47 $25.11 $26.73 $28.34 $29.98 $31.60 $33.22 $38.16 $39.78 $50.19 $51.83 $53.45
1650 $17.10 $17.10 $17.10 $17.10 $20.64 $22.36 $24.06 $25.77 $27.48 $29.18 $30.89 $32.60 $34.30 $39.33 $41.03 $51.53 $53.24 $54.96
1750 $17.10 $17.10 $17.10 $17.10 $21.07 $22.85 $24.65 $26.44 $28.24 $30.01 $31.81 $33.60 $35.40 $40.49 $42.29 $52.86 $54.67 $56.45
1850 $17.10 $17.10 $17.10 $17.10 $21.48 $23.36 $25.22 $27.11 $28.98 $30.85 $32.72 $34.60 $36.48 $41.66 $43.53 $54.19 $56.08 $57.96
1950 $17.10 $17.10 $17.10 $17.10 $21.89 $23.85 $25.81 $27.77 $29.73 $31.68 $33.64 $35.60 $37.56 $42.82 $44.78 $55.53 $57.49 $59.45
STATE OF FLORIDA
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SUBMIT THIS FORM TO YOUR LOCAL TAX COLLECTOR OFFICE
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POWER OF ATTORNEY FOR A MOTOR VEHICLE, MOBILE HOME OR VESSEL
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I/We hereby name and appoint, __________________________________________________________, to be my/our
(Full Legibly Printed Name is Required)
lawful attorney-in-fact, to act for me/us, in applying for an original or duplicate certificate of title, to register, transfer title,
or record a lien to the motor vehicle, mobile home or vessel described below, and to print my/our name and sign their
name, in my/our behalf. My attorney-in-fact can also do all things necessary to the application or any other related
instrument and to bind me/us in as sufficient a manner as I/we myself/ourselves could do, were I/we personally present
and signing the same.
With full power of substitution and revocation, I/we hereby ratify and confirm whatever my/our said attorney-in-fact may
lawfully do or cause to be done in the virtue hereof.
CHECK ONE: Motor Vehicle Mobile Home Vessel
Year
Make/Manufacturer
Body Type
Title Number
Vehicle/Vessel Identification Number
NOTICE TO OWNER(S): COMPLETE THIS FORM IN ITS ENTIRETY PRIOR TO SIGNING.
UNDER PENALTIES OF PERJURY, I/WE DECLARE THAT I/WE HAVE READ THE FOREGOING DOCUMENT AND
THAT THE FACTS STATED IN IT ARE TRUE.
_________________________________________________ __________________________________________________
(Signature of Owner "Grantor”) (Legibly Printed Name of Owner "Grantor")
________________________________________________________________________________________________________
(Driver License, Identification Card or FEID Number for Owner) (Date of Birth for Owner, if applicable)
________________________________________________________________________________________________________
(Owner’s Address ) (City) State) (Zip)
_________________________________________________ __________________________________________________
(Signature of Co-Owner "Grantor,” if applicable) (Legibly Printed Name of Co-Owner "Grantor," if applicable)
________________________________________________________________________________________________________
(Driver License, Identification Card or FEID Number for Co-Owner) (Date of Birth for Co-Owner, if applicable)
________________________________________________________________________________________________________
(Co-Owner’s Address) (City) (State) (Zip)
This non-secure power of attorney form may be used when an individual or entity appointed as the attorney-in-fact will
be completing the odometer disclosure statement as the buyer only or the seller only. However, this form cannot be
used to allow an individual or entity (such as a dealership) to sign as both buyer and seller for the purpose of disclosing
the odometer reading. This may be accomplished only with the secure power of attorney (HSMV 82995) when:
(a) the title is physically being held by the lienholder; or
(b) the title is lost.
NOTE: A licensed dealer and his/her employees are considered a single entity.
Check your local phone book government pages or visit the following website for current mailing addresses:
http://www.flhsmv.gov/offices/
HSMV 82053 (Rev. 12/11) S www.flhsmv.gov
