HSMV 84490 Form PDF Details

The HSMV 84490 form, a comprehensive document issued by the State of Florida Department of Highway Safety and Motor Vehicles, serves a crucial role in the official certification process for a diverse range of vehicles, including motor vehicles, motorcycles, and mobile homes that have been reconstructed, rebuilt, or altered in significant ways from their original condition. This form encompasses an array of details starting with a basic description of the vehicle, such as year, make, identification number, color, body length, and title information, to ensure accurate identification in official records. Crucially, it requires builders to disclose major component parts used in the vehicle's construction or repair, distinguishing between new, used, repaired, aftermarket, or homemade parts, and to provide source or Vehicle Identification Number (VIN) wherever applicable. For vehicles not aimed at daily use but for special occasions and public interest events, such as custom vehicles or street rods, there's a separate section attesting to compliance with state equipment and safety requirements relevant to the model year. Applicants must assert under penalty of perjury, the truthfulness of all provided information, confirming that no material information has been omitted about the vehicle's condition and compliance with Florida and Federal Motor Vehicle Safety Standards. The form concludes with sections for official use only, including VIN verification and vehicle inspection outcomes, to finalize the certification process. This document not only ensures compliance with regulatory standards but also safeguards public safety by mandating detailed disclosures about the vehicle's construction and conformity.

QuestionAnswer
Form Name HSMV 84490 Form
Form Length 2 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 30 sec
Other names florida 84490, florida dmv 84490, form hsmv 84490, rebuilt title form

Form Preview Example

STATE OF FLORIDA

DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES

STATEMENT OF BUILDER

 

 

REBUILT

 

 

 

 

ASPT

 

 

KIT CAR

 

 

 

 

 

 

 

OTHER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION I. DESCRIPTION OF

 

 

 

MOTOR VEHICLE

 

 

 

 

MOTORCYCLE

 

 

 

 

MOBILE HOME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Year

Make

 

Identification Number

 

 

 

Color

Body

 

 

 

Length

 

 

 

 

 

 

 

 

 

 

2.

Title Number:

 

 

 

 

 

 

 

 

 

 

Title State:

 

 

 

 

 

 

 

 

3.

Other/Title Number:

 

 

 

 

 

 

 

 

Title State:

 

 

 

 

 

 

 

 

 

4.

Motor Vehicle/Motorcycle is complete and in road operable condition.

 

 

 

 

 

(Initials)

 

 

Mobile Home is habitable for residential or commercial purposes.

 

 

 

 

 

(Initials)

SECTION II. MAJOR COMPONENT PARTS USED IN THE BUILDING/REPAIR PROCESS

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.

1. This section is not applicable as the

 

 

 

Motor Vehicle

 

 

Motorcycle

or

Mobile Home

 

was purchased from

 

 

on

 

 

 

20

, in

complete rebuilt or ASPT condition.

 

 

 

 

 

 

 

 

 

2.List the major component parts used in the building/repair process (if additional space is needed, please use form HSMV 84491).

Part

New Used Repaired

Aftermarket Homemade

Source/VIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.When Section II (1) is not applicable, describe the repairs made in detail. (If additional space is needed, please use form HSMV 84491. Attach the original MSO, bill of sale(s), or receipt(s) for all major component parts (must contain name, address, telephone, and signature of seller).

4.Number of Receipts:

SECTION III. CUSTOM VEHICLE OR STREET ROD

The following statements are required to be attested to according to section 320.0863, Florida Statutes. Failure to attest to these statements will cause this agency to reject your application.

The vehicle will not be used for general daily transportation but will be maintained for occasional transportation, exhibitions, club activities, parades, tours, or other functions of public interest and similar uses.

The vehicle meets state equipment and safety requirements for motor vehicles that were in effect in this state as a condition of sale in the year listed as the model year on the certificate of title.

By checking the boxes above and by signature below, I acknowledge and attest to the statements above as my written statement relating to a custom vehicle or street rod.

Signature

Date

HSMV 84490 (Rev. 04/16)

STATEMENT OF BUILDER FORM HSMV 84490

Page 2

 

 

SECTION IV.

APPLICANT INFORMATION AND SIGNATURE

 

 

Date:

The undersigned hereby certifies that the vehicle conforms to Florida and Federal Motor Vehicle Safety Standards.

UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING DOCUMENT AND THAT THE FACTS PROVIDED HEREIN ARE TRUE. NO MATERIAL INFORMATION REGARDING THE MOTOR VEHICLE, MOTORCYCLE, OR MOBILE HOME HAS BEEN OMITTED.

PRINTED NAME OF APPLICANT/BUSINESS

STREET ADDRESS

CITYSTATEZIP

TELEPHONE NUMBER:

SIGNATURE OF APPLICANT/BUSINESS

PRINTED NAME OF APPLICANT/BUSINESS

STREET ADDRESS

CITYSTATEZIP

TELEPHONE NUMBER:

SIGNATURE OF APPLICANT/BUSINESS

SECTION V. HSMV O&&/ USE ONLY

HSMV CE signature below attests to the VIN verification and vehicle inspection requirements. PRVIP Inspector attests to vehicle inspection only.

VIN:

 

Title Number:

 

 

 

 

 

 

 

D-1:

 

Title State:

 

 

Odometer:

 

 

 

 

 

 

 

D-2:

 

Year:

 

 

 

 

Make:

 

 

D-3:

 

Body:

 

 

 

Color:

 

 

 

 

 

 

 

 

D-4:

 

Audit #:

 

 

 

 

 

Region #:

 

 

 

 

 

 

 

 

 

 

 

 

 

Please mark the appropriate answer:

 

 

 

 

 

 

 

 

 

 

Secondary VIN Verified

 

 

 

Yes

 

No

Federal Decal

 

 

Yes

 

No

 

 

 

 

Replacement VIN Plate/Decal

 

 

Yes

 

No

Vehicle Painted Prior to Inspection

 

 

Yes

 

No

This ASPT/Vehicle resembles a: __________________________

Odometer Replacement Notice:

 

 

Yes No

Mobile Home Use Only:

Mobile Home was measured

Comments:

 

 

 

FRVIS

 

 

Yes

No

Previous Rebuilt Title

 

Yes

No

NICB Check

 

 

Yes

No

Tax Due On: __________________________

Component Parts Marked

Yes

No

Flood Damaged

 

 

Yes

No

Theft

 

 

Yes

No

With Tongue

or

Without Tongue

Under penalties of perjury, I declare that I have made inspection of this motor vehicle, motorcycle, or mobile home and completed Section V based on that inspection.

 

 

 

 

 

 

 

 

 

 

 

Signature of HSMV Compliance Examiner

 

Print Name of HSMV Compliance Examiner

Region #

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

i n

t

of

PRVIP Inspector

 

 

Print Name of PRVIP Inspector

Co/Agy #

 

 

 

S g

a ure

 

 

 

 

 

 

 

 

HSMV 84490 (Rev. 04/16)

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1. Start filling out your florida rebuilt title form with a selection of major blanks. Collect all of the important information and make certain absolutely nothing is forgotten!

Step no. 1 for completing statement of builder form hsmv 84490

2. Soon after finishing the last section, head on to the subsequent part and enter the essential particulars in these blank fields - Part, New Used Repaired, Aftermarket Homemade, SourceVIN, When Section II is not, form HSMV Attach the original MSO, name address telephone and, Number of Receipts, SECTION III, CUSTOM VEHICLE OR STREET ROD, The following statements are, The vehicle will not be used for, and By checking the boxes above and by.

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Be really mindful while filling in By checking the boxes above and by and When Section II is not, since this is the part where most people make some mistakes.

3. Completing SECTION IV, APPLICANT INFORMATION AND SIGNATURE, Date, The undersigned hereby certifies, PRINTED NAME OF APPLICANTBUSINESS, PRINTED NAME OF APPLICANTBUSINESS, STREET ADDRESS, STREET ADDRESS, CITY, STATE, ZIP, CITY, STATE, ZIP, and TELEPHONE NUMBER is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

CITY, STATE, and ZIP of statement of builder form hsmv 84490

4. The subsequent paragraph requires your attention in the subsequent parts: HSMV CE signature below attests to, VIN, Title Number, Title State, Odometer, Year, Body, Audit, Make, Color, Region, Please mark the appropriate answer, FRVIS, Secondary VIN Verified, and Federal Decal. Be sure to fill in all of the needed details to go onward.

Filling out segment 4 in statement of builder form hsmv 84490

5. This form needs to be completed within this segment. Further there can be found a comprehensive set of blanks that need to be filled in with correct information for your form usage to be complete: This ASPTVehicle resembles a, Mobile Home was measured, Yes, Theft, Yes, With Tongue, Without Tongue, Comments, Under penalties of perjury I, and completed Section V based on, Signature of HSMV Compliance, Print Name of HSMV Compliance, Region, Date, and Signature of PRVIP Inspector.

How one can prepare statement of builder form hsmv 84490 stage 5

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