Fillable TEMENT OF BUILDER STA SE STATE OF FLORIDA (Florida)

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TEMENT OF BUILDER STA SE STATE OF FLORIDA (Florida)

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STATE OF FLORIDA
DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES
STA
TEMENT OF BUILDER
(Additional Sheet)
REBUILT ASPT COMBINED KIT CAR OTHER:
SE
CTION I. Description of:
MOTOR VEHICLE MOTORCYCLE MOBILE HOME
1. _________ _____________ _________________________ __________ ____________ ______________
Year Make Identification Number Color Body Length
SECTION II. MAJOR COMPONENT PARTS USED IN THE BUILDING/REPAIR PROCESS
2. Please continue to list the major component parts used in the building/repair process.
Part
New Used Repaired After Market Homemade Source/VIN
_______
___ _______ _______ __________ ___________ ___________ _____________________________
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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.
HSMV 84491 (Rev. 2/17)
3. Please continue to describe any repairs made.
SECTION III. TO BE COMPLETED AND SUBMITTED WITH ALL APPLICATIONS
Date: ____________________
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING DOCUMENT AND THAT THE
FACTS STATED IN IT ARE TRUE. NO MATERIAL INFORMATION REGARDING THE MOTOR VEHICLE,
MOTORCYCLE, OR MOBILE HOME HAS BEEN OMITTED.
__________
________________________________
PRINTED NAME OF CO-APPLICANT/BUSINESS
__________
________________________________
SIGNATURE OF CO-APPLICANT/BUSINESS
__________________________________________
PRINTED NAME OF APPLICANT/BUSINESS
__________________________________________
SIGNATURE OF APPLICANT/BUSINESS
HSMV 84491 (Rev. 2/17)
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TEMENT OF BUILDER STA SE STATE OF FLORIDA (Florida)

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Completed 22 May 2022

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