FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES
DIVISION OF MOTORIST SERVICES
SUBMIT THIS FORM TO YOUR LOCAL TAX COLLECTOR OFFICE
www.flhsmv.gov/offices/
VEHICLE IDENTIFICATION NUMBER AND ODOMETER VERIFICATION
PART A - OWNER’S VEHICLE IDENTIFICATION AFFIDAVIT AND ODOMETER DECLARATION
(Completion of this part requires a physical inspection of the vehicle by the owner)
AFFIDAVIT:
DATE:
This is to certify that I, the undersigned, am the lawful owner of the motor vehicle described on this form and that I have,
on the date entered above, made a physical inspection of the motor vehicle and have recorded the vehicle identification
number and other identification information and the odometer reading and certification in the spaces provided on this form.
VEHICLE IDENTIFICATION (MOTOR NUMBER ALL MAKES THROUGH 1954 - IDENTIFICATION NUMBER 1955 AND LATER)
Vehicle Identification Number Year Make Color Body
Previous State Vehicle Titled In
ODOMETER DECLARATION
WARNING: Federal and State law require that you state the mileage in connection with an application for a
Certificate of Title. Failure to complete or providing a false statement may result in fines and/or imprisonment.
I /WE STATE THAT THIS 5
OR
6 DIGIT ODOMETER NOW READS
,
.XX (NO TENTHS)
MILES, DATE READ
/
/ AND I/WE HEREBY CERTIFY THAT TO THE BEST OF MY KNOWLEDGE
THE ODOMETER READING:
1. reflects ACTUAL MILEAGE. 2. is IN EXCESS OF ITS MECHANICAL LIMITS. 3. is NOT THE ACTUAL MILEAGE.
UNDER PENALTY OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING
DOCUMENT AND THAT THE FACTS STATED IN IT ARE TRUE.
(Owner/ Purchaser Signature)
Printed name
(Seller's Signature)
Printed name
PART B – VERIFICATION OF THE VEHICLE IDENTIFICATION NUMBER
This section requires a physical inspection under the windshield and in the door jamb to verify the vehicle identification number (VIN)
for the motor vehicle described in this form. If the motor vehicle was manufactured prior to 1955, the motor number must be verified.
If the verification is performed by someone other than a Notary, the VIN verification can be performed by a Florida Licensed Dealer,
Law Enforcement Officer, Military Police Officer, or Florida Compliance Examiner/Inspector (Division of Motorist Services/Tax
Collector employee). Complete this section on all used motor vehicles, including trailers, (with abbreviation of “TL” with a weight of
2,000 pounds or more) not currently titled in Florida.
I, the undersigned, certify that I have physically inspected the above described vehicle and find the vehicle identification number
under the windshield and in the door jamb to be identical to the vehicle identification number recorded on this form.
UNDER PENALTY OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING DOCUMENT
AND THAT THE FACTS STATED IN IT ARE TRUE.
Date: (Seal)
Commissioned Name of Florida Notary:
(Print, Type or Stamp)
Notary’s Signature:
If other than a Notary, check the box below that applies, and sign and complete the corresponding fields. Verified by:
Florida Compliance Examiner/ Military Police Officer/
Inspector(DMS/TC Employee) Law Enforcement Officer
Printed Name:
Florida Licensed Dealer
Signature:
Florida Compliance Examiner/Inspector Name: Badge or ID #:
Law Enforcement Agency Name: LEO Badge #:
Florida Dealer Name: Florida Dealer #:
◆
NOTICE: ANY ALTERATION OR ERASURE MAY VOID THIS DOCUMENT
♦
HSMV 82042 (REV. 01/15/21) www.flhsmv.gov
