NOTE: This form should be printed on the official letterhead of the acknowledging depository.
Household Moving Services Certificate of Deposit Assignment Form
(legal name of applicant for Intrastate Moving License), Assignor, does hereby assign, transfer, and set over unto the Florida
Department of Agriculture and Consumer Services, Assignee, all right, title, and interest to and in Certificate of Deposit
number entitled and issued by
(name and address of depository)
Depository, in the amount of $25,000.00 , excluding interest payable thereon. This assignment is made as security pursuant
to Chapter 507, Florida Statutes, Household Moving Services, for (legal name and address of intrastate mover). Assignee takes this
Assignment for the use and benefit of any consumer who is injured as a result of the Principal’s fraud, misrepresentation,
breach of contract, misfeasance, malfeasance, financial failure, or any violation of Chapter 507, Florida Statutes, Household
Moving Services. Liability for these injuries may be determined in an administrative proceeding of the Department or through a
civil action in a court of competent jurisdiction, However, claims against this assigned certificate of deposit shall only be paid,
in amounts not to exceed the determined liability for these injuries, by order of the Department in an administrative
proceeding. This assignment includes any substitution or renewals to the Certificate of Deposit described, and shall remain in
effect until Assignee notifies Depository in writing of the cancellation of this assignment.
Assignee is authorized to draw against the above Certificate of Deposit pursuant to Chapter 507, Florida Statutes, Household
Moving Services, and Depository is directed to pay up to the Principal Sum to Assignee upon demand. Partial draft is
permitted. Any payments made pursuant to this assignment shall constitute acquittance of Depository. Depository shall not
pay any portion of the Principal Sum to Assignor without prior written cancellation of this assignment from the Assignee. This
Certificate of Deposit may not be encumbered in any way, and any attempted encumbrance is void.
Signature of Assignor
Depository Acknowledgement of Assignment
The Assignor’s signature above compares correctly with our files. Principal Sum is $ _______________, and the above
assignment will be considered valid and honored until written cancellation is received from Assignee.
Depository Name:
Zip Code:
Telephone Number:
Name of Authorized Depository Officer:
Title of Authorized Depository Officer:
Signature of Authorized Depository Officer