Form Hsmv 82363 – 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 SALVAGE TITLE/CERTIFICATE OF DESTRUCTION

INSTRUCTIONS ON REVERSE SIDE

Flood Vehicle (check box)

1					APPLICANT INFORMATION
TOTAL LOSS BY INSURANCE COMPANY							UNINSURED OR SELF-INSURED
TOTAL SALVAGE LOSS			TOTAL THEFT LOSS				SALVAGE BY OWNER(S) (No Insurance Company Involved)
Insurance Company's Name							Owner's Name
Address							Address
City			State		Zip		City	State	Zip
Date Declared Total Loss							Date of Loss
and Compensation Paid
Policy Number	Claim Number			FEID Number			DL Number/FEID #	Sex and Date of Birth
2					VEHICLE DESCRIPTION

3 IMPORTANT: SEE VEHICLE IDENTIFICATION NUMBER VERIFICATION ON REVERSE SIDE OF THIS FORM

4	SALVAGE TITLE/CERTIFICATE OF DESTRUCTION NOTATION INFORMATION

7

ODOMETER DECLARATION

I/WE STATE THAT THIS MOTOR VEHICLE'S

5 OR

6 DIGIT ODOMETER NOW READS

'

. XX (NO

TENTHS) MILES, DATE READ

/

/

, AND TO THE BEST OF MY KNOWLEDGE THAT IT REFLECTS THE

ACTUAL MILEAGE OF THE VEHICLE DESCRIBED IN THIS DOCUMENT UNLESS ONE OF THE FOLLOWING IS CHECKED::

8	APPLICANT ATTESTMENT SIGNATURES

UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING DOCUMENT AND THAT THE FACTS STATED IN IT ARE TRUE. I/WE AGREE TO DEFEND THE TITLE AGAINST ALL CLAIMS.

Applicant or Authorized Agent's Signature

Applicant or Authorized Agent's HAND PRINTED Name

NOTE: Properly Assigned Certificate of Title MUST BE ATTACHED Applicant or Authorized Agent's Printed Signature MUST be on this Application

HSMV 82363 (Rev. 8/00)S

VEHICLE IDENTIFICATION NUMBER VERIFICATION

COMPLETION OF THIS PART REQUIRES A PHYSICAL INSPECTION OF THE MOTOR VEHICLE DESCRIBED ON THIS FORM BY A LICENSED DEALER, NOTARY PUBLIC, POLICE OFFICER OR FLORIDA DIVISION OF MOTOR VEHICLE COMPLIANCE

EXAMINER/INSPECTOR, COMPLETING THE VERIFICATION OF THE VEHICLE IDENTIFICATION NUMBER. COMPLETE THIS BLOCK ON ALL USED MOTOR VEHICLES, INCLUDING TRAILERS WITH A WEIGHT OF 2,000 POUNDS OR MORE WHICH

ARE NOT PREVIOUSLY TITLED IN FLORIDA.

I, the undesigned, certify that I have physically inspected the vehicle described on side 1 of this form and found the

vehicle identification number to be:

				Vehicle Identification Number
DATE				SIGNATURE				PRINTED NAME
Any Law Enforcement Officer					Badge or ID Number
Florida or out-of-state Dealer License Number									(Notary Stamp)

Florida Compliance Examiner/Inspector Badge or ID Number

WHEN DOES THE VIN VERIFICATION ON THIS FORM NOT HAVE TO BE COMPLETED?

THE VIN VERIFICATION ON THIS FORM DOES NOT HAVE TO BE COMPLETED ON NEW MOTOR VEHICLES, MOBILE HOMES, TRAVEL TRAILERS, CAMPING TRAILERS, FIFTH WHEEL RECREATIONAL VEHICLES, TRAILERS OR SEMI TRAILERS WITH A NET WEIGHT OF LESS THAN 2,000 POUNDS, WHEN A FLORIDA CERTIFICATE OF TITLE IS SUBMITTED AS PROOF OF OWNERSHIP OR WHEN FORM HSMV 82042 HAS BEEN COMPLETED AND IS ATTACHED.

WHEN SHOULD THE ODOMETER DECLARATION ON THIS FORM NOT BE COMPLETED?

THE ODOMETER DECLARATION IN SECTION 7 OF THIS FORM DOES NOT HAVE TO BE COMPLETED WHEN THE VEHICLE BEING TITLED IS EXEMPT FROM ODOMETER DISCLOSURE REQUIREMENTS. EXEMPTIONS: WHEN THE VEHICLE IS TEN YEARS OLD OR OLDER, HAS A GROSS VEHICLE WEIGHT RATING (GVWR) OF MORE THAN 16,000 POUNDS OR IS NOT SELF PROPELLED.

WHO IS AUTHORIZED TO USE THIS FORM?

Any person, or authorized agent of any person or business, required to make application for a Florida Salvage Certificate of Title/Certificate of Destruction.

WHEN SHOULD THIS FORM BE USED?

I . When an insurance company has paid a ''Total Loss'' on a motor vehicle or mobile home and must make application for a Salvage Certificate of Title/Certificate of Destruction in the name of the insurance company.

2 When an Uninsured or Self-Insured has a motor vehicle or mobile home that has been wrecked or damaged, and at the time of loss the cost of repairing or rebuilding the motor vehicle or mobile home is 80% or more of the cost to the owner of replacing the wrecked or damaged motor vehicle or mobile home with one of like kind or quality.

FILING

1.ALL APPLICABLE SECTIONS OF THIS FORM MUST BE COMPLETED LEGIBLY.

2.THIS FORM MUST BE DOCUMENTED BY THE ATTACHMENT OF:

(A)FLORIDA CERTIFICATE OF TITLE.

OR

(B)MANUFACTURER'S CERTIFICATE OF ORIGIN.

OR

(C)OUT-OF-STATE TITLE OR OTHER OFFICIAL PROOF OF OWNERSHIP.

NOTE: When an insurance company pays the vehicle owner to replace the wrecked or damaged vehicle with one of like kind or quality, or when an insurance company pays the owner upon the theft of the motor vehicle or mobile home, the insurance company must have the title/Certificate of Destruction issued in their name.

NOTE: A Certificate of Title will not be issued on a new or used motor vehicle that has been stolen from an out-of-state owner, dealer, or manufacturer until the motor vehicle has been recovered, and the required VIN

verification can be performed.

NOTE: This form has been combined with form HSMV 82042.

HSMV 82363 (Rev. 8/00) S