Fillable Application for Certificate of Title Form 82040

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Application for Certificate of Title Form 82040

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Application for Certificate of Title Form 82040
HSMV form 82040 is the application for title for the purchaser. A completed 82040 should be
submitted with every title you give to us for processing. This is a multi-use form, so don’t feel like
every box needs to have something in it. Some of the sections may not apply to your particular
transaction. There are sections for Dealers Only, as well as Vessel Only. The instructions
provided below are for personal vehicle title application.
There are a couple of general guidelines you should follow with this form:
•
No errors, cross-outs, write-overs. If you make an error, please complete a new 82040
•
All applicants must sign this form
Let’s take this section by section.
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
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."
OR 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
RE
P
LICA
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
.XX (NO TENTHS) _____ /_____ / ________ DIGIT ODOMETER NOW READS 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
HSMV 82040 – REV. 11/15 RULE
15C-21.001, FAC
www.flhsmv.gov
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19
20
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23 24
25
26
27
28
29
30
31
32
33
34
Vessel Only
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36
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38
39
40
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43
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45
46
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49
8
MOTOR VEHICLE IDENTIFICATION NUMBER VERIFICATION
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 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
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, t
he 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_
COMMISSIONED NAME OF FLORIDA NOTARY: _____________________________
(Print, Type or Stamp)
NOTARY'S SIGNATURE
9
SALES TAX EXEMPTION CERTIFICATION
THE 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:
CONSUMER’S CERTIFICATE OF EXEMPTION NUMBER
PURCHASER (STATE AGENCIES, COUNTIES, ETC.) HOLDS VALID EXEMPTION CERTIFICATE
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)
10
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
APPLICATION 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 FORE
GOING DOCUMENT AND THAT THE FACTS STATED IN IT ARE TRUE.
SIGNATURE OF APPLICANT (OWNER) Date SIGNATURE OF APPLICANT (CO-OWNER) Date
13
RELEASE OF SPOUSE OR HEIRS INTEREST
The undersigned person(s) st
ate(s) as follows: That
(Name of Deceased)
died on
(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:
Name of Applicant(s) (Print orType)
RESIDENTS OF FLORIDA AND ALL VESSEL OWNERS, RESIDING IN FLORIDA OR OUT OF STATE, SHOULD SUBMIT THIS FORM AND 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
RULE 15C-21.001, FAC
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Section 1 Owner/Applicant Information
This is the personal information section.
1 Application Type (check the appropriate box)
Is it an original- MCO or out of state title becoming a FL title for the first time?
Or, is it a current Florida title and you’re just transferring ownership?
2 Vehicle Type (check the appropriate box)
Off-Highway Vehicle (ATV)
Motor Vehicle (This includes: Trailers and Motorcycles)
Mobile Home
Vessel
3 Check this box if you are requesting the title to be printed
This is if you are requesting a paper title as opposed to an electro
nic title.
If this box is not checked title will be electronic.
*** This choice will affect the fees you will be charged***
4 Are you a Florida resident/Are you an alien? (check the appropriate boxes)
These boxes apply to both the owner and co-owner (if applicable).
5 “OR” / “AND” (check the appropriate box)
How do your customers want their names joined; the conjunction “or” or “and”?
OR- requires only one signature for future title transactions
AND- requires all signatures for future title transactions
****If no conjunction is chosen, we will enter “AND” when processing****
6 Owner’s County of Residence
Where do you claim residency? This is for sales tax purposes.
7 Owner’s name
Please complete this row completely with:
Owner’s name
Owner’s e-mail address (optional)
Owner’s DOB
Owner’s Sex
Owner’s Florida Driver License number*
*If you do not have a Florida Driver License number, remember to include a copy of your
Identification (Valid Out of State Driver License or Passport) with your work.
If titling to a business, remember to include the appropriate business information (FEID#, SUNBIZ)
8 Co-Owner’s name
All of the information included with Owner (#7) should be included for the co-owner
as well.
9 Owner’s Mailing Address
This is a mandatory field. The information should be taken from the Driver License.
10 Co-Owner’s Mailing Address
If the co-owner shares the same address as the owner SAA (Same As Above)
can be entered.
11 Owner’s Physical Address
This is also mandatory. If the mailing address and physical address are the same,
SAA can be entered.
We want to know the physical address of the Mobile Home. If this situation doesn’t
Apply to you, leave it blank.
12 Mobile Home Physical Location
We want to know the physical address of the Mobile Home. If this situation doesn’t
Apply to you, leave it blank.
13 Mail to Customer Name
If you want the title mailed to a different person, complete this row.
14 Mail to Customer Address
If you want the title mailed to a different address, complete this row.
Section 2 Motor Vehicle, Mobile Home Or Vessel Description
15 Vehicle / Vessel Identification Number
Enter either the 17 digit VIN or the 12 digit Hull Identification Number (HIN).
16 Make / Manufacturer
Enter the Make or the Manufacturer information here.
17 Year
Enter the Year of the Vehicle/Vessel.
18 Body
If this is a Vessel VS goes here.
If this is a Mobile Home, MH goes here.
19 Color
Enter the color for Motor Vehicles.
Think “primary colors”…what color does it look like?
20 Florida Title Number
If applicable, enter the Florida Title Number.
21 Previous State of Issue
If the title you are submitting is from another state, please write that state’s
abbreviation in this space.
22 License Plate or Vessel Registration Number
If this is for a Motor Vehicle:
Enter the plate number to transfer.
If there is no plate to transfer enter the word, “NEW.”
Tell us whether you want it renewed for 1 or 2 years.
If you want a specialty plate, enter that info here.
If this is for a Vessel:
Enter the FL number.
Tell us whether you want it renewed for 1 or 2 years.
23 Weight
This is a required field.
If you have a FL title, the weight will be shown on the face of the title.
If you have an Out of State title, please provide the weight- we cannot process
the title without the weight. You can google the year & make & model.
24 Length
For Vessels and Mobile Homes. Provide the length in Feet and Inches- not just
Inches.
25 BHP/CC
This field is for Motorcycles and Mopeds. Please enter the CCs.
26 GVW/LOC
GVW stands for Gross Vehicle Weight and is for Trucks with an empty weight over 5000
pounds. The owner is required to declare the GVW.
LOC stands for the Location Code of a Mobile Home.
27 Van Use, If Applicable
If the motor vehicle is a van, check the appropriate box. If it is a cargo van, and
The empty weight is over 5000 pounds, the owner will have to declare a GVW
(see #12)
Fields 28 – 35 are specifically for Vessels:
28 Type (check the appropriate box)
This field is for vessels. What type of vessel is it?
29 Hull Material (check the appropriate box)
This field is also for vessels. What is the hull material?
30 Propulsion (check the appropriate box)
This field is also for vessels. What kind of motor does the vessel have?
31 Fuel (check the appropriate box)
This field is for vessels. What kind of fuel does the vessel use?
32 Draft of Vessel
If the vessels is 26 feet or longer, draft feet or inches needs to be entered here.
33 Use of Vessel (check the appropriate box)
Will the new owner register the vessel as pleasure or commercial?
34 Previous Out of State Registration Number
If the title you are submitting is an Out of State title, please list the prior registration
number in this area.
35 Previously Federally Documented Vessel (check the appropriate box)
If the vessel was previously documented and is coming out of documentation, attach the
supporting paperwork.
Section 3 Brands, Usage and Type and Section 4 Lienholder Information
36 Check all applicable boxes
If the vehicle is branded, check the appropriate boxes in this section. Also, what is the
“use” of the vehicle or vessel…is it being leased or is it private?
Section 4 Lienholder Information
If you have a lien (making payments) on this vehicle, that information goes in this area.
37 Verify if ELT Customer
Some lienholders have “signed up” to have their titles held electronically. This means
they do not want a paper title printed and mailed to them. They want an electronic
version. You can call your lienholder to see if they are ELT customer.
38 FEID#, DL#, or DMV Account#
If the lienholder is on the ELT list, their DMV Account # and FEID #.
If the lienholder is not on the ELT list, please provide their FEID # in this field.
39 Date of Lien
Insert the date of the lien in this field.
40 Lienholder’s Name
Insert the Lienholder’s name in this field.
41 Lienholder’s e-mail Address
If you have that information it can be entered here. If not, it’s ok if you leave it
blank.
42 Lienholder’s Address
Please complete this section with the Lienholder’s address.
43 Lienholder Authorization to have the Title Mailed to the Customer
Florida is a non-title-holding state. This means that titles with liens are sent to
the lienholder. The lienholder can authorize the title to be sent to the owner by
checking this box (except for vessels) and signing in the signature area next to it.
Section 5 Transfer Type and Section 6 Odometer Disclosure
How did Ownership Change?
44 How Was the Vehicle/Vessel/Mobile Home Acquired? (check the appropriate box)
Sale, gift, repossession, court order, other.
45 Date Acquired
Enter the Date of Sale in this section.
Section 6 Odometer Declaration
The odometer reading, date, and certification go in this area.
46 5 or 6 Digit Odometer (check the appropriate box)
Does the odometer have 5 digits for the reading or 6?
Hint- digital odometers usually are 6 digits.
47 Odometer Declaration
Place the odometer reading in these boxes. If the odometer is exempt, place the word
“EXEMPT” in the boxes.
48 Date
Enter the date the odometer reading is being recorded.
49 Attestment
Check the applicable box. Is the odometer reading:
Actual
In Excess
Not Actual
Section 7 Sales Tax Report and Vehicle Trade in Information (This section
only applies to Licensed Dealers)
Section 8 Motor Vehicle Identification Number Verification
This section is completed for all vehicles that are currently titled in another state.
50 Vehicle Identification Number
A physical inspection of the car is necessary to complete this. Physically look at the
VIN plate on the vehicle, compare it to the certificate of title and transpose it onto
this section.
51 Date
Enter the date the VIN was verified.
52 Signature
The person who verifies the VIN signs in this spot. Florida Notary, Police Officer, FL
DMV/Tax Collector Employee.
53 Printed Name
The printed name of the person who verified the VIN goes here.
54 Law Enforcement Officer
Printed name of law enforcement officer.
55 Badge # or Notary Seal
Badge # of law enforcement officer or military police officer; or Florida Notary seal.
Section 9 Sales Tax Exemption Certification
There will be times when no sales tax is collected. In those situations, utilize this section to
tell us why.
56 Purchaser Holds Valid Exemption Certificate
Put the Certificate of Exemption Number in this area. Also submit a copy of the
exemption certificate.
57 Motor Vehicle/Mobile Home/Vessel Will be Used Exclusively For Rental
If the Vehicle/Mobile Home/Vessel will be used for rental, enter the sales tax
registration number in this area.
58The described Motor Vehicle/Mobile Home/Vessel is not subject to Sales or Use
Tax
Inheritance, Gift, Divorce Decree, Transfer Between Husband and Wife, Even Trade or Trade
Down. In dealer transactions, the most common scenario is “Even Trade or
Trade Down.”
59 Other
If the reason for 3 is Even Trade or Trade Down, the information of vehicle that was
traded gets entered here.
Section 10 Repossession Declaration
If you finance vehicles, mobile homes, or vessels, this section is for the repossession should
you need to repossess.
60 Check the applicable box
Section 11 Non-Use and Other Certifications
This section has multiple purposes. Check the applicable box or boxes
61 I certify that the Certificate of Title is Lost or Destroyed
This box is checked with certain death case scenarios
62 The Vehicle Identified Will Not Be Operated On The Streets And Highways Of This
State Until Properly Registered
This box is checked in the event of a “title only”- no tag is being issued.
****A temporary tag cannot be issued if this box is checked*****
63 The Vessel Identified Will Not Be Operated On the Waters Of This State
Until Properly Registered
This box is checked in the event of a “title only”-no registration is being issued.
The FL number still needs to be transferred, but a Non-Use registration will be
produced.
64 Other
This space can be utilized for 2 things:
Name is the same, i.e. “Jim Jones and James Jones are one in the same”
Disposal affidavit- A tag is being transferred onto the new vehicle and your
customer did not trade in a vehicle. In that instance, put the Year, Make
and VIN of the vehicle the tag came off of in this area.
Section 12 Application Attestment and Signatures
All persons who are applying for title need to sign in this section. If more than two
people intend to take title, more than one 82040 can be used. Original signatures
required, photocopies not accepted.
65 Signature of Applicant (Owner)
The first listed owner signs and dates here.
66 Signature of Applicant (Co-Owner)
Th
e second listed owner signs and dates here.
Section 13 Release of Spouse or Heirs Interest
This section is completed in the event of a death case. If you should acquire a vehicle that is because
of a death, we advise you contact the Tax Collector’s office. Death cases can become quite involved.
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Application for Certificate of Title Form 82040

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Completed 17 February 2022

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