Fillable Form 84490 (Florida)

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Form 84490 (Florida)

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The Form 84490 (Florida) form is 2 pages long and contains:

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  • 6 check-boxes
  • 119 other fields

Country of origin: US
File type: PDF

BROWSE FLORIDA FORMS

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1.
2. Titl
e Number: Title State:
3. Other/Title Number: Title State:
4. Motor Vehicle/Motorcycle is complete and in road operable condition. (Initials)
Mobile Home is habitable for residential or commercial purposes. (Initials)
STATE OF FLORIDA
DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES
STATEMENT OF BUILDER
SECTION I. DESCRIPTION OF MOTOR VEHICLE MOTORCYCLE MOBILE HOME
REBUILT ASPT KIT CAR OTHER:
SECTION II. MAJOR COMPONENT PARTS USED IN THE BUILDING/REPAIR PROCESS
Note: Major component parts defined as: For motor vehicles other than motorcycles, any fender, hood, bumper,
cowl assembly, rear quarter panel, trunk lid, door, deck lid, floor pan, engine, frame, transmission, catalytic converter
or airbag.
1. This section is not applicable as the Motor Vehicle Motorcycle or Mobile Home
was purchased from on 20 , in
complete rebuilt or ASPT condition.
2. List the major component parts used in the building/repair process (if additional space is needed, please use form
HSMV 84491).
Part
New Used Repaired Aftermarket Homemade Source/VIN
3. When Section II (1) is not applicable, describe the repairs made in detail. (If additional space is needed, please use
form HSMV 84491. Attach the original MSO, bill of sale(s), or receipt(s) for all major component parts (must contain
name, address, telephone, and signature of seller).
4. Number of Receipts:
HSMV 84490 (Rev. 04/16)
Year
Make
Identification Number
Color
Body Length
The following statements are required to be attested to according to section 320.0863, Florida Statutes. Failure to attest
to these statements will cause this agency to reject your application.
The vehicle will not be used for general daily transportation but will be maintained for occasional transportation,
exhibitions, club activities, parades, tours, or other functions of public interest and similar uses.
The vehicle meets state equipment and safety requirements for motor vehicles that were in effect in this state as a
condition of sale in the year listed as the model year on the certificate of title.
SECTION III. CUSTOM VEHICLE OR STREET ROD
By checking the boxes above and by signature below, I acknowledge and attest to the statements above as my written
statement relating to a custom vehicle or street rod.
D-1: Title State: Odom
eter:
D-2: Year: Make:
D-3: Body: Color:
D-4: Audit #: Region #:
Please mark the appropri
ate answer: FRVIS Yes No
Secondary VIN Verified Yes No Previous Rebuilt Title Yes No
Federal Decal Yes No NICB Check Yes No
Replacement VIN Plate/Decal Yes No Tax Due On: __________________________
Vehicle Painted Prior to Inspection Yes No Component Parts Marked Yes No
This ASPT/Vehicle resembles a: __________________________ Flood Damaged Yes No
Theft Yes No
Mobile Home Use Only: Mobile Home was measured With Tongue or Without Tongue
Comments:
Under penalties of perjury, I declare that I have made inspection of this motor vehicle, motorcycle, or mobile home
and completed Section V based on that inspection.
STATEMENT OF BUILDER FORM HSMV 84490 Page 2
HSMV 84490 (Rev. 04/16)
Date
Signature of HSMV Compliance Examiner
Signature of PRVIP Inspector
SECTION IV. APPLICANT INFORMATION AND SIGNATURE
Date:
The undersigned hereb
y certifies that the vehicle conforms to Florida and Federal Motor Vehicle Safety Standards.
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING DOCUMENT AND THAT THE FACTS PROVIDED
HEREIN ARE TRUE. NO MATERIAL INFORMATION REGARDING THE MOTOR VEHICLE, MOTORCYCLE, OR MOBILE HOME HAS
BEEN OMITTED.
PRINTED NAME OF APPLIC
ANT/BUSINESS
STREET ADDRESS
CITY STATE ZIP
TELEPHONE NUMBER:
SIGNATURE OF APPLICANT/BUSINESS
PRINTED NAME OF APPLIC
ANT/BUSINESS
STREET ADDRESS
CITY STATE ZIP
TELEPHONE NUMBER:
SIGNATURE OF APPLICANT/BUSINESS
Odometer Replacement Notice:
Yes
No
SECTION V. HSMV O&&/USE ONLY
HSMV CE signature below attests to the VIN verification and vehicle inspection requirements. PRVIP Inspector attests to vehicle inspection only.
VIN:
Title Number:
Date
Region #
Co/Agy #
Print Name of HSMV Compliance Examiner
Print Name of PRVIP Inspector
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Form 84490 (Florida)

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Completed 21 July 2020

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