Application For Notice Of Lien Form – Fill Out and Use This PDF

STATE OF FLORIDA

DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES

DIVISION OF MOTOR VEHICLES

Neil Kirkman Building - Tallahassee, FL 32399-0610

APPLICATION FOR NOTICE OF LIEN / REASSIGNMENT OF LIEN OR

NOTICE TO FIRST LIENHOLDER OF SUBSEQUENT LIEN

1	MOTOR VEHICLE, MOBILE HOME, OFF-HIGHWAY VEHICLE OR VESSEL
DESCRIPTION
IDENTIFICATION NUMBER					VESSEL REGISTRATION NUMBER
MAKE/MANUFACTURER		YEAR			MODEL			WT.-LGTH.-BHP
COLOR			TYPE			USE
CERTIFICATE OF TITLE NUMBER				PREVIOUS ISSUE DATE			LICENSE PLATE NUMBER

2			NOTICE OF LIEN
		LIENHOLDER INFORMATION
DATE OF LIEN		FEID # DL # AND SEX AND DATE OF BIRTH	DMV ACCOUNT #	LIENHOLDER NAME
LIENHOLDER ADDRESS			CITY		STATE	ZIP CODE
Electronic title and lien participant (Electronic title only).
If the lienholder authorizes the department to send title to the owner,				_____________________________________________
check box and countersign. (DOES NOT APPLY TO VESSELS)				Signature of Lienholder’s Representative

One of the following boxes must be checked.

A security agreement, retain title contract, conditional bill of sale, chattel mortgage or other similar instrument was executed prior to the filing of this notice of lien.

This notice of lien is being filed before a security agreement, retain title contract, conditional bill of sale, chattel mortgage or other similar instrument is being executed.

UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING				Date_______________________________
DOCUMENT AND THAT THE FACTS STATED IN IT ARE TRUE.
________________________________________________________			____________________________________________________________
	Signature of Registered Owner		Signature of Registered Co-Owner
________________________________________________________			____________________________________________________________
	Street Address (Owner)			Street Address (Co-Owner)
________________________________________________________			____________________________________________________________
City	State	Zip Code	City	State	Zip Code
3	APPLICATION FOR REASSIGNMENT OF LIEN

of (Month/Year)________________, covering the motor vehicle, mobile home, off-highway vehicle or vessel described in section

one of this form and request that the Florida Certificate of Title, which was issued on (Month/Day/Year) _____________________,

be re-issued to show such lien as now being held by the undersigned applicant and represents that on this date there is a balance as principal still due and unpaid.

UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING DOCUMENT AND THAT THE FACTS STATED IN IT ARE TRUE.

________________________________________________________	By __________________________________________________________
Name of Assignee (New Lienholder)	Signature of Lienholder's Representative
	Title _________________________________________________________

Address _________________________________________________ City _________________________ State _________ Zip Code __________

UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING DOCUMENT AND THAT THE FACTS STATED IN IT ARE TRUE.

________________________________________________________	By __________________________________________________________
Name of Assignor (Lienholder currently shown on Title)	Signature of Lienholder's Representative
	Title _________________________________________________________

HSMV 82139 (Rev. 06/05) S

http://www.hsmv.state.fl.us

4	NOTICE TO FIRST LIENHOLDER OF SUBSEQUENT LIEN

Date _____________________________

To:____________________________________________________________________________________________

First Lienholder

Address:________________________________________________________________________________________

City and State:______________________________________________________ Zip Code _____________________

You are the first lienholder on Title Number __________________ covering the motor vehicle, mobile home,

off-highway vehicle or vessel described on the reverse of this form, which is recorded in the office of the DIVISION OF MOTOR VEHICLES in Tallahassee, Florida. FLORIDA STATUTES REQUIRE THE FIRST LIENHOLDER TO SUBMIT

THE CERTIFICATE OF TITLE TO THE DIVISION OF MOTOR VEHICLES WITHIN TEN (10) DAYS AFTER RECEIPT OF THIS NOTICE, UNLESS THE DMV DATABASE REFLECTS AN ELECTRONIC TITLE. This is to advise you that I have this date placed an additional lien on the above described motor vehicle, vessel, off-highway vehicle or mobile home with:

_______________________________________________________________________________________________

Name of Subsequent Lienholder

_______________________________________________________________________________________________

Address

_______________________________________________________________________________________________

City

State

Zip Code

Please forward the above mentioned Certificate of Title with this request attached, if applicable, to the DIVISION OF MOTOR VEHICLES, at Tallahassee, Florida, for the purpose of recording the subsequent lien thereon. When the subsequent lien is recorded, the Division of Motor Vehicles will mail a Certificate of Title to you, if applicable, as first lienholder.

UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING DOCUMENT AND THAT THE FACTS STATED IN IT ARE TRUE.

Signed: __________________________________________	___________________________________________
Signature of Owner	Signature of Co-Owner
Name: ________________________________________	___________________________________________
Print or Type	Print or Type

INSTRUCTIONS WHEN USING SECTION 4 OF THIS FORM:

Prepare in duplicate and send a copy of this form by registered or certified mail with the returned receipt requested to the first lienholder, as shown on the DMV database record. Submit the original copy of the form to a county tax collector’s office with the return receipt signed by the first lienholder and the lien recording fee provided by section 328.14(6), Florida Statutes, for vessels, by section 319.32(1) and (2)(a), Florida Statutes, for motor vehicles and mobile homes and sections 317.0006(5)(a), & 317.0007(1), Florida Statutes, for off-highway vehicles.

Notice to the First Lienholder: If you fail, neglect, or refuse to forward the certificate of title to the department within 10 days from the date of the owner’s request, the department, on the written request of the subsequent lienholder or an assignee thereof, shall make written demand to you for the return of such certificate of title for the notation of the second or subsequent lien or encumbrance.

THIS FORM IS A COMBINATION OF FORMS HSMV 82139, HSMV 82140, HSMV 82365 AND HSMV 87004.

HSMV 82139 (Rev. 06/05) S

http://www.hsmv.state.fl.us