HSMV 84901 at a glance
What it is: The Complaint Affidavit of the Division of Motorist Services, HSMV 84901 (Rev. 10/21), describes the nature of your complaint.
Who signs: Under SIGN, enter the Signature and the Date.
What to bring and attach to HSMV 84901
Enclose copies of any documentation you have related to your complaint.
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, print off the form and mail the complaint form and copies of all related documentation.
A filled-in HSMV 84901 example: a car buyer complains about a dealer
How to fill out HSMV 84901, box by box
Type of complaint
Under TYPE OF COMPLAINT, mark Motor Vehicle Dealer, Mobile Home Dealer, Mobile Home Manufacturer, RV Dealer or Manufacturer, Odometer Fraud or Other.
Complainant information
Under COMPLAINANT INFORMATION, enter the Name and Date of Birth.
Enter the Address, City, County, State and Zip Code.
Enter the Home or Cell Phone Number, Work Phone Number, Fax Number and Email Address.
Enter the Driver License or ID Number. In lieu of FL Driver License or ID Number, an Out of State or U.S. Territory Driver License can be used.
In lieu of Driver License or ID Number, a U.S. or Out of Country Passport can be used: enter the Passport ID Number.
Dealership information
Under DEALERSHIP INFORMATION, enter the Dealership Name and Dealer License Number.
Enter the Address. Then enter the City, County, State and Zip Code.
Enter the Fax Number, Email Address and Salesperson Name.
Vehicle or mobile home (MH) inspection information
Under VEHICLE OR MOBILE HOME (MH) INSPECTION INFORMATION, enter the Year/Make/Model, Date Purchased and Date Delivered.
Enter the Vehicle Identification Number (VIN) and Tag Number.
Mobile home, recreational vehicle or park trailer information
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.
Enter the Name of Manufacturer, Address, City, County, State and Zip Code.
Enter the HUD Label. HUD Label is a red or silver metal tag on rear of unit.
Enter the Florida Seal Number. If unit is a recreational vehicle or park trailer, Florida Seal # will either be near the HUD label or front of unit.
Complaint affidavit
Under COMPLAINT AFFIDAVIT, describe the nature of your complaint, listing events in the order in which they occurred. It is important to verify that dates listed are accurate.
Under What actions do you feel will satisfy your complaint, explain what actions you feel will satisfy your complaint.
Sign
Under SIGN, enter the Signature and the Date.
More rules for HSMV 84901
Division of Motorist Services, Bureau of Dealer Services, Motor Vehicle Field Operations Regional Offices: Region 1 Motor Vehicle Field Operations 1135 Banks Road Margate, Florida 33063 Telephone - (954) 969-4216 Fax - (954) 969-4237 Email - DmvRegion1@flhsmv.gov, responsible for Broward County. Region 2 Motor Vehicle Field Operations 318 Southeast 25th Avenue Ocala, Florida 34471 Telephone - (352) 732-1267 Fax - (352) 732-1459 Email - DmvRegion2@flhsmv.gov, responsible for Alachua, Gilchrist, Lake, Levy, Marion, Putnam County. Region 3 Motor Vehicle Field Operations 9550 Regency Square Boulevard, Suite 100 Jacksonville, Florida 32225 Telephone - (904) 365-2681 Fax - (904) 723-2001 Email - DmvRegion3@flhsmv.gov, responsible for Baker, Bradford, Columbia, Clay, Flagler, Duval, Nassau, St. Johns, Union County. Region 4 Motor Vehicle Field Operations 1697 North Woodland Boulevard, Suite 111D Deland, FL 32720 Telephone - (386) 327-9220 Fax - (386) 736-5092 Email - DmvRegion4@flhsmv.gov, responsible for Brevard, Seminole, Volusia County. Region 5 Motor Vehicle Field Operations 4101 Clarcona-Ocoee Road, Suite 160 Orlando, Florida 32810 Telephone - (407) 445-7400 Fax - (407) 848-1896 Email - DmvRegion5@flhsmv.gov, responsible for Orange, Osceola County. Region 6 Motor Vehicle Field Operations NET PARK, Suite 2228 5701 East Hillsborough Avenue Tampa, Florida 33610 Telephone - (813) 612-7110 Fax - (813) 612-7111 Email - DmvRegion6@flhsmv.gov, responsible for Citrus, Hernando, Hillsborough, Pasco, Pinellas, Polk, Sumter County. Region 7 Motor Vehicle Field Operations Neil Kirkman Building 2900 Apalachee Parkway, Room B-139, MS-76 Tallahassee, Florida 32399-0600 Telephone - (850) 617-2999 Fax - (850) 617-5180 Email - DmvRegion7@flhsmv.gov, responsible for Bay, Calhoun, Dixie, Escambia, Franklin, Gadsden, Gulf, Hamilton, Holmes, Jackson, Jefferson, Lafayette, Leon, Liberty, Madison, Okaloosa, Santa Rosa, Suwannee, Taylor, Walton, Wakulla, Washington County. Region 71 - Panama City Sub-Office 6030 County Road 2321 Panama City, Florida 32404 Telephone - (850) 767-3660 Fax - (850) 872-7764 Email - DmvRegion7@flhsmv.gov. Region 72 - Pensacola Sub-Office 100 Stumpfield Road Pensacola, Florida 32503 Telephone - (850) 475-5415 Fax - (850) 475-5423 Email - DmvRegion7@flhsmv.gov. Region 8 Motor Vehicle Field Operations 1201 9th Avenue West Bradenton, Florida 34205 Telephone - (941) 723-4551 Fax - (941) 723-4553 Email - DmvRegion8@flhsmv.gov, responsible for Charlotte, Collier, Desoto, Glades, Hardee, Hendry, Highlands, Lee, Manatee, Sarasota County. Region 9 Motor Vehicle Field Operations 901 Northpoint Parkway, Suites 115 & 116 West Palm Beach, Florida 33407 Telephone - (561) 640-6820 Fax - (561) 640-6835 Email - DmvRegion9@flhsmv.gov, responsible for Indian River, Martin, Okeechobee, Palm Beach, St. Lucie County. Region 10 Motor Vehicle Field Operations 12601 NW 42 Avenue Opa Locka, Florida 33054 Telephone - (786) 804-4190 Fax - (305) 953-3160 Email - DmvRegion10@flhsmv.gov, responsible for Dade, Monroe County BDS Regional Offices (Rev. 6/2026)
Common questions about HSMV 84901
Where do I file it?
View the list 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.
Sources
[1] HSMV 84901 (Rev. 10/21), Complaint Affidavit, Division of Motorist Services, Florida Department of Highway Safety and Motor Vehicles (the Official source link on this page).