Form Hsmv 82137 – Fill Out and Use This PDF

STATE OF 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/

APPLICATION FOR AN ORIGINAL/DUPLICATE

DERELICT MOTOR VEHICLE CERTIFICATE AND REQUEST TO CANCEL TITLE

This form must be used by the owner/seller of a derelict motor vehicle/trailer who is arranging for the delivery and/or sale of the derelict motor vehicle/trailer to a licensed salvage motor vehicle dealer or a registered secondary metals recycler when the title, salvage title or certificate of destruction is not available. The derelict motor vehicle must be worth less than $1,000 or the derelict trailer (TL) must be worth less than $5,000 and must be at least ten model years old (count model year as year one). This form may also be used to apply for a duplicate Derelict Certificate.

VEHICLE/TRAILER MAY NEVER BE TITLED AGAIN AND MUST BE DISMANTLED OR SCRAPPED.

SECTIONS 1, 2, AND 3 SHOULD BE COMPLETED IF APPLYING FOR AN ORIGINAL DERELICT CERTIFICATE.

SECTION 1 SHOULD BE COMPLETED BY THE SALVAGE DEALER/RECYCLER, IF APPLYING FOR A DUPLICATE DERELICT CERTIFICATE.

VIN:	Year:	Make:	Body:	Color:			Purchase Price:
Name of Owner/Seller:		Owner/Seller’s Driver License/ID Card Number and State of Issue:
		(Legible copy must be attached.)
Address of Owner/Seller:							THUMB PRINT SECTION
						If the seller is not the owner of record
						of the above described vehicle, the
I certify that I am the owner/seller of the derelict vehicle/trailer described above and the title, salvage title, or certificate of
						licensed salvage dealer or registered
destruction is not available. I certify that this vehicle is either a motor vehicle (worth less than $1,000) or a trailer (worth less than						secondary metals recycler at the time
$5,000) which is at least ten model years old, (required under s. 319.30, Florida Statutes). I certify that there are no undisclosed						of sale must obtain a smudge-free
						right thumb print or other digit if the
liens against this vehicle. If I am the seller, I further attest that possession of the motor vehicle/trailer was obtained through lawful						seller has no right thumb.
means along with ownership rights. I understand this statement will be filed with the Florida Department of Highway Safety and
Motor Vehicles and I am authorizing my title record to be cancelled preventing this vehicle/trailer from ever being titled again.
I hereby authorize _____________________________________________________ of _____________________________________________________________
(Print Name of Driver)		(Print name of Transporter Business)
to act on my behalf and transport the vehicle described above to a licensed salvage motor vehicle dealer or registered secondary metals recycler.
Under Penalties of Perjury, I Declare That I Have Read The Foregoing Document and That The Facts Stated In It Are True.
Signature(s) of Owner(s):						Date:

SECTION 2

This section must be completed by the transporter being hired to transport the vehicle for the owner/seller to a licensed salvage motor vehicle dealer or secondary metals recycler and cannot be used for a vehicle being towed from private property for third parties or being purchased by towing operators. If the owner/seller or the salvage motor vehicle dealer or secondary metals recycler transports the motor vehicle/trailer in lieu of a transporter, this section may be left blank.

Transporter (when applicable) must complete this section:

Location of Pickup:

Name of Company or Person Transporting:

Name of Driver Transporting:

Florida DL Number of Person Transporting:

I certify the owner/seller of the vehicle described above provided proper personal identification, completed section one of this form and signed the form in my presence when I picked the vehicle up at the above location.

Under Penalties of Perjury, I Declare That I Have Read The Foregoing Document and That The Facts Stated In It Are True.

Signature of Transporter	Date:
Printed Name:	Person’s Business Title:

SECTION 3

The licensed salvage motor vehicle dealer or registered secondary metals recycler must complete this section:

Name of Business Acquiring the Vehicle:

Licensed Salvage Motor Vehicle Dealer License Number or Secondary Metals Recycler’s Registration Number:

Licensed Salvage Motor Vehicle or Secondary Metals Recycler’s E-mail Address:

I am notifying the Florida Department of Highway Safety and Motor Vehicles, as required by law, within 24 hrs. (excluding weekends/holidays) of receiving the derelict motor vehicle/trailer by delivering this completed form to a tax collector's office/license plate agency. I certify that I paid less than $1,000 for the motor vehicle or less than $5,000 for the trailer described in this application and agree to hold the motor vehicle/trailer for three (3) business days (excluding weekends/holidays) after the Derelict Certificate is issued before dismantling or destruction. I acknowledge it is a punishable felony of the third degree, as provided in s. 775.082, 775.083 or 775.084, Florida Statutes, if this statement contains false information.

Under Penalties of Perjury, I Declare That I Have Read The Foregoing Document and That The Facts Stated In It Are True.

Signature of Buyer:	Date:
Printed Name:	Person’s Business Title:

Check your local phone book government pages or visit the following website for current mailing addresses: http://www.flhsmv.gov/offices/

HSMV 82137 (06/11) S

www.flhsmv.gov