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VEHICLES-
DEVISIONOF MOTORIST SERVICES
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Year
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THAT
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NOTE:
the title
IS physically being held by the henholde,; or
the title IS lost
licensed dealer and hrs/her employees are considered a single entity.
STATE OF FLORIDA
DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES – DIVISION OF MOTORIST SERVICES
SUBMIT THIS FORM TO YOUR LOCAL TAX COLLECTOR OFFICE
www.flhsmv.gov/offices/
POWER OF ATTORNEY FOR A MOTOR VEHICLE, MOBILE HOME OR VESSEL
(Date)
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-O
Co-Own
wner’
.r
s
s
Address
ress)
)
(Zip)
(Zip)
(
(State)
State)
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
