Fillable Form 84901 (Florida)

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Form 84901 (Florida)

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Country of origin: US
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FOR OFFICIAL USE ONLY
TYPE OF COMPLAINT
Motor Vehicle Dealer
Mobile Home Dealer
Mobile Home Manufacturer
RV Dealer/Manufacturer
Odometer Fraud
Other
Date Opened: ________________________ Date Closed: _______________________
Closing Code: __________________________________________________________
Complaint #: ___________________________________________________________
Investigator: ____________________________________________________________
COMPLAINANT INFORMATION
Name: _______________________________ Date of Birth: ___________ E-mail Address: ______________________
Address: _________________________________________________________________________________________
City/County/State/Zip Code: __________________________________________________________________________
Home Telephone Number: ____________Work Telephone Number: ___________ FAX Number: _________________
Driver License/ID Number (In lieu of FL DL/ID, an Out of State/U.S. Territory DL can be used ):________________________
In lieu of DL or ID, a U.S. or Out of Country Passport can be used : __________________________________________
DEALERSHIP INFORMATION
Dealership Name: ___________________________________________________________________________________
Address: _________________________________________________________________________________________
City/County/State/Zip Code: _________________________________________________________________________
E-mail Address: ___________________________________ FAX Number: ___________________________________
Dealer License Number (if known): ____________________________________________________________________
Salesperson’s Name (if known): _______________________________________________________________________
VEHICLE/MOBILE HOME/INSPECTION INFORMATION
Make/Model/Year: ______________________________ Date Purchased: __________ Date Delivered: __________
Vehicle Identification Number: ____________________________________ Tag Number: _______________________
(Complete this section only if a mobile home, recreational vehicle or park trailer is involved in your complaint.)
Name of Manufacturer: ______________________________________________________________________________
Manufacturer’s Address: _____________________________________________________________________________
City/County/State/Zip Code: __________________________________________________________________________
HUD Label (red/silver metal tag on rear of unit): __________________________________________________________
Florida Seal Number if unit is a recreational vehicle or park trailer (by HUD Label or front): _______________________
HSMV 84901 (Rev. 02/16) Please complete page two of this form.
DIVISION OF MOTORIST SERVICES
COMPLAINT AFFIDAVIT
COMPLAINT AFFIDAVIT _____ Page 2
DESCRIBE THE NATURE OF YOUR COMPLAINT: Please explain your complaint, listing events in the order in
which they occurred. It is important to verify that dates listed are accurate. Enclose copies of any documentation you
have related to your complaint.
WHAT ACTIONS DO YOU FEEL WILL SATISFY YOUR COMPLAINT?
Note: You may complete the form, save the document to your computer, scan and attach ALL supporting documents,
including purchase agreement, contracts receipts, cancelled checks, proof of vehicle insurance, registration, inspection
reports, warranty documents, repair invoices or any other documents relating to your complaint and email us your
completed file. Otherwise, please print off the form and mail the complaint form and copies of all related documentation
so that we may address your concerns as quickly as possible.
Please view the list below and locate the Regional Office responsible for the county the dealer is located and either email
or mail your complaint and all supporting documents to the appropriate regional office.
SIGNATURE: ______________________________________________ DATE: ______________________________________
HSMV 84901 (Rev. 02/16)
Region 1/9
Motor Vehicle Field Operations
1135 Banks Road
Margate, Florida 33063
Telephone = (954) 969-4216
FAX = (954) 969-4237
Responsible for Broward County
DmvRegion1@flhsmv.gov
901 Northpoint Parkway, Suites 115 & 116
West Palm Beach, Florida 33407
Telephone = (561) 640-6820
FAX = (561) 640-6835
Responsible for Indian River, Okeechobee, Martin,
Palm Beach and St. Lucie Counties
DmvRegion9@flhsmv.gov
Region 2
Motor Vehicle Field Operations
318 Southeast 25th Avenue
Ocala, Florida 34471
Telephone = (352) 732-1267
FAX = (352) 732-1459
Responsible for Alachua, Gilchrist, Lake, Levy,
Marion and Putnam Counties
DmvRegion2@flhsmv.gov
Region 3
Motor Vehicle Field Operations
9550 Regency Square Boulevard, Suite 100
Jacksonville, Florida 32225
Telephone = (904) 365-2681
FAX = (904) 723-2001
Responsible for Baker, Bradford, Clay, Columbia,
Flagler, Duval, Nassau, St. Johns and Union
Counties DmvRegion3@flhsmv.gov
Region 4/5
Motor Vehicle Field Operations
2575 South Volusia Avenue, Suite 300
Orange City, Florida 32763
Telephone = (386) 736-5107
FAX = (386) 775-5233
Responsible for Brevard, Seminole and Volusia
Counties
DmvRegion4@flhsmv.gov
4101 Clarcona-Ocoee Road, Suite 160
Orlando, Florida 32810
Telephone = (407) 445-7400
FAX = (407) 445-7411
Responsible for Orange and Osceola Counties
DmvRegion5@flhsmv.gov
Region 6
Motor Vehicle Field Operations
NET PARK, Suite 2228
5701 East Hillsborough Avenue
Tampa, Florida 33610
Telephone = (813) 612-7110
FAX = (813) 612-7111
Responsible for Citrus, Hernando, Hillsborough,
Pasco, Pinellas, Polk and Sumter Counties
DmvRegion6@flhsmv.gov
Region 7
Motor Vehicle Field Operations
Neil Kirkman Building
2900 Apalachee Parkway, Room B-142, MS-76
Tallahassee, Florida 32399-0600
Telephone = (850) 617-2999
FAX = (850) 617-5180
Responsible for Dixie, Franklin, Gadsden, Hamilton,
Jefferson, Lafayette, Leon, Liberty, Madison,
Suwanee, Taylor and Wakulla Counties
DmvRegion7@flhsmv.gov
Region 71 - Panama City Sub-Office
6030 County Road 2321
Panama City, Florida 32404
Telephone = (850) 767-3660
FAX = (850) 872-7764
Responsible for Bay, Calhoun, Gulf, Jackson,
Holmes, Walton and Washington Counties
DmvRegion7@flhsmv.gov
Region 72 – Pensacola Sub-Office
100 Stumpfield Road
Pensacola, Florida 32503
Telephone = (850) 475-5415
FAX = (850) 475-5423
Responsible for Escambia, Okaloosa and Santa
Rosa Counties
DmvRegion7@flhsmv.gov
Region 8
Motor Vehicle Field Operations
323 10th Avenue West, Suite 200
Palmetto, Florida 34221
Telephone = (941) 723-4551
FAX = (941) 723-4553
Responsible for Charlotte, Collier, Desoto, Glades,
Hardee, Hendry, Highlands, Lee, Manatee and
Sarasota Counties
DmvRegion8@flhsmv.gov
Region 10
Motor Vehicle Field Operations
12601 NW 42
nd
Avenue
Opa Locka, Florida 33056
Telephone = (786) 804-4190
FAX = (305) 953-3160
Responsible for Dade and Monroe Counties
DmvRegion10@flhsmv.gov
Revised 1/7/2019
Division of Motorist Services
BUREAU OF DEALER SERVICES
MOTOR VEHICLE FIELD OPERATIONS - REGIONAL OFFICES
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Form 84901 (Florida)

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Completed 19 July 2020

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