LAKE COUNTY TAX COLLECTOR
PG 1 of 1LCTC Rev. 01/20
P.O. Box 327 Tavares, FL 32778-0327 • 352-343-9602 • www.laketax.com
Year Make Title VIN
I afﬁrm that did not take possession of the above described vehicle,
vessel or mobile home. The name was erroneously entered and without fraudulent intention. The vehicle
was in fact sold to on for $ .
The actual date of the sale was not .
This is to certify that the above described vehicle registered with license plate number
has been sold, traded or otherwise disposed of, is currently not operational or is in storage and will not
be operated on the streets and highways of this state.
The above described vehicle has been continuously maintained in dead storage and was not used at any
time during the registration period for which the exemption is being claimed.
The following license plate number is lost, destroyed or stolen. Therefore, the license
plate is not available to surrender. If found, the license plate will not be afﬁxed to any vehicle or trailer.
The name of and are one in the
UNDER PENALTY OF PERJURY, I CERTIFY THAT I HAVE READ THE “MULTI-PURPOSE AFFIDAVIT”
AND THAT THE FACTS STATED IN IT ARE TRUE.
NOT FOR USE ON MOBILE HOME RETIREMENT
Signature of Seller/Owner Driver License/ID Card Number Date
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