Form Hsmv 84901 PDF Details

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QuestionAnswer
Form NameForm Hsmv 84901
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesdmv complaints florida, complaint affidavit florida, florida affidavit, dmv dealer complaint form

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DIVISION OF MOTORIST SERVICES

COMPLAINT AFFIDAVIT

FOR OFFICIAL USE ONLY

TYPE OF COMPLAINT

Motor Vehicle Dealer

Mobile Home Dealer

Mobile Home Manufacturer

RVDealer/Manufacturer

Odometer Fraud

Other

Date Opened: ________________________ Date Closed: _______________________

Closing Code: __________________________________________________________

Complaint #: ___________________________________________________________

Investigator: ____________________________________________________________

COMPLAINANT INFORMATION

Name: _______________________________ Date of Birth: ___________ E-mail Address: ______________________

Address: _________________________________________________________________________________________

City/County/State/Zip Code: __________________________________________________________________________

Home Telephone Number: ____________Work Telephone Number: ___________ FAX Number: _________________

Driver License/ID Number (In lieu of FL DL/ID, an Out of State/U.S. Territory DL can be used ):________________________

In lieu of DL or ID, a U.S. or Out of Country Passport can be used : __________________________________________

DEALERSHIP INFORMATION

Dealership Name: ___________________________________________________________________________________

Address: _________________________________________________________________________________________

City/County/State/Zip Code: _________________________________________________________________________

E-mail Address: ___________________________________ FAX Number: ___________________________________

Dealer License Number (if known): ____________________________________________________________________

Salesperson’s Name (if known): _______________________________________________________________________

VEHICLE/MOBILE HOME/INSPECTION INFORMATION

Make/Model/Year: ______________________________ Date Purchased: __________ Date Delivered: __________

Vehicle Identification Number: ____________________________________ Tag Number: _______________________

MOBILE HOME, RECREATIONAL VEHICLE, OR PARK TRAILER INFORMATION

(Complete this section only if a mobile home, recreational vehicle or park trailer is involved in your complaint.)

Name of Manufacturer: ______________________________________________________________________________

Manufacturer’s Address: _____________________________________________________________________________

City/County/State/Zip Code: __________________________________________________________________________

HUD Label (red/silver metal tag on rear of unit): __________________________________________________________

Florida Seal Number if unit is a recreational vehicle or park trailer (by HUD Label or front): _______________________

HSMV 84901 (Rev. 02/16)

Please complete page two of this form.

COMPLAINT AFFIDAVIT _____

Page 2

DESCRIBE THE NATURE OF YOUR COMPLAINT: Please explain your complaint, listing events in the order in which they occurred. It is important to verify that dates listed are accurate. Enclose copies of any documentation you have related to your complaint.

WHAT ACTIONS DO YOU FEEL WILL SATISFY YOUR COMPLAINT?

Note: You may complete the form, save the document to your computer, scan and attach ALL supporting documents, including purchase agreement, contracts receipts, cancelled checks, proof of vehicle insurance, registration, inspection reports, warranty documents, repair invoices or any other documents relating to your complaint and email us your completed file. Otherwise, please print off the form and mail the complaint form and copies of all related documentation so that we may address your concerns as quickly as possible.

Please view the list below and locate the Regional Office responsible for the county the dealer is located and either email or mail your complaint and all supporting documents to the appropriate regional office.

SIGNATURE: ______________________________________________ DATE: ______________________________________

HSMV 84901 (Rev. 02/16)

Division of Motorist Services

BUREAU OF DEALER SERVICES

MOTOR VEHICLE FIELD OPERATIONS - REGIONAL OFFICES

Region I/IX

Motor Vehicle Field Operations

1135 Banks Road

Margate, Florida 33063

Telephone = (954) 969-4216

FAX = (954) 969-4237

Responsible for Broward County

DmvRegion1@flhsmv.gov

901 Northpoint Parkway, Suites 115 & 116

West Palm Beach, Florida 33407

Telephone = (561) 640-6820

FAX = (561) 640-6835

Responsible for Indian River, Okeechobee, Martin, Palm Beach and St. Lucie Counties

DmvRegion9@flhsmv.gov

Region II

Motor Vehicle Field Operations

318 Southeast 25th Avenue

Ocala, Florida 34471

Telephone = (352) 732-1267

FAX = (352) 732-1459

Responsible for Alachua, Columbia, Gilchrist, Lake, Levy, Marion and Putnam Counties

DmvRegion2@flhsmv.gov

Region III

Motor Vehicle Field Operations 3200 Armsdale Road, Suite 13 Jacksonville, Florida 32218 Telephone = (904) 924-1524 FAX = (904) 924-1525 or 924-1530

Responsible for Baker, Bradford, Clay, Flagler, Duval, Nassau, St. Johns and Union Counties

DmvRegion3@flhsmv.gov

Region IV/V

Motor Vehicle Field Operations

2575 South Volusia Avenue, Suite 300

Orange City, Florida 32763

Telephone = (386) 736-5107

FAX = (386) 775-5233

Responsible for Brevard, Seminole and Volusia Counties

DmvRegion4@flhsmv.gov

4101 Clarcona-Ocoee Road, Suite 160

Orlando, Florida 32810

Telephone = (407) 445-7400

FAX = (407) 445-7411

Responsible for Orange and Osceola Counties

DmvRegion5@flhsmv.gov

Region VI

Motor Vehicle Field Operations

NET PARK, Suite 2228

5701 East Hillsborough Avenue

Tampa, Florida 33610

Telephone = (813) 612-7110

FAX = (813) 612-7111

Responsible for Citrus, Hernando, Hillsborough, Pasco, Pinellas, Polk and Sumter Counties

DmvRegion6@flhsmv.gov

Region VII

Motor Vehicle Field Operations

Neil Kirkman Building

2900 Apalachee Parkway, Room B-142, MS-76

Tallahassee, Florida 32399-0600

Telephone = (850) 617-2999

FAX = (850) 617-5180

Responsible for Dixie, Franklin, Gadsden, Hamilton, Jefferson, Lafayette, Leon, Liberty, Madison, Suwanee, Taylor and Wakulla Counties

DmvRegion7@flhsmv.gov

Region VII - Panama City Sub-Office

6030 County Road 2321

Panama City, Florida 32404

Telephone = (850) 767-3660

FAX = (850) 872-7764

Responsible for Bay, Calhoun, Gulf, Jackson, Holmes, Walton and Washington Counties

DmvRegion7@flhsmv.gov

Region VII – Pensacola Sub-Office

100 Stumpfield Road

Pensacola, Florida 32503

Telephone = (850) 475-5415

FAX = (850) 475-5423

Responsible for Escambia, Okaloosa and Santa Rosa Counties

DmvRegion7@flhsmv.gov

Region VIII

Motor Vehicle Field Operations

323 10th Avenue West, Suite 200

Palmetto, Florida 34221

Telephone = (941) 723-4551

FAX = (941) 723-4553

Responsible for Charlotte, Collier, Desoto, Glades, Hardee, Hendry, Highlands, Lee, Manatee and Sarasota Counties

DmvRegion8@flhsmv.gov

Region X

Motor Vehicle Field Operations

7795 West Flagler Street Suite 82C

Miami, Florida 33144

Telephone = (305) 265-3003

FAX = (305) 265-3060

Responsible for Dade and Monroe Counties

DmvRegion10@flhsmv.gov

Revised 2/12/16

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