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 Do you want the certificate of title to
remain electronic?
yes no
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 Appears 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)
City
State
Zip
Co-Owner’s/Lessee’s Mailing Address (Mandatory)
City
State
Zip
Owner’s/Lessee’s Physical Street Address in Florida (Mandatory)
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
BRANDS
USAGE AND TYPE
Check A
licable Boxes
SHORT TERM LEASE
LONG TERM LEASE
REBUILT
POLICE VEHICLE
PRIVATE USE
TAXI CAB
FLOOD VEHICLE
ILEV VEHICLE
ASSEMBLED FROM PARTS REPLICA KIT CAR GLIDER KIT MANUFACTURER’S BUY BACK
AUTONOMOUS VEHICLE
ELECTRIC VEHICLE
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)
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 _________/___________/______________
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 NET SELLING PRICE 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. 06/12
