Form HSMV 84490 at a glance
What it is: Form HSMV 84490, Statement of Builder, is a State of Florida Department of Highway Safety and Motor Vehicles form.
Who signs: Enter the Printed Name of Applicant/Business, Street Address, City, State, Zip and Telephone Number(S), and sign on Signature Of Applicant/Business.
What to bring and attach to Form HSMV 84490
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).
A filled-in Form HSMV 84490 example: a builder rebuilds a car
How to fill out Form HSMV 84490, box by box
Rebuilt, ASPT, Kit Car or Other
Mark REBUILT, ASPT, KIT CAR or OTHER; after OTHER, fill in the line.
Section I. Description of
In Section I, Description of, mark Motor Vehicle, Motorcycle or Mobile Home.
Enter the Year, Make, Identification Number, Color, Body and Length.
Title Number and Other/Title Number
In box 2 of Section I, enter the Title Number and the Title State.
In box 3 of Section I, enter the Other/Title Number and the Title State.
Initials
In box 4 of Section I, enter the Initials that the Motor Vehicle/Motorcycle is complete and in road operable condition.
In box 5 of Section I, enter the Initials that the Mobile Home is habitable for residential or commercial purposes.
Section II. Major component parts: 1. This section is not applicable
In box 1 of Section II, mark Motor Vehicle, Motorcycle or Mobile Home, then fill in after "from" and after "on ____20", for a purchase in complete rebuilt or ASPT condition; this section is then not applicable.
Major component parts are 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. In addition to the previously mentioned, major component parts for electric, hybrid, or plug-in vehicles or trucks include any electric traction motor, electronic transmission, charge port, DC power converter, onboard charger, power electronics controller, thermal system, transaction battery pack, or airbag.
Section II. Major component parts: 2. List the major component parts
In box 2 of Section II, list the major component parts used in the building/repair process; if additional space is needed, use form HSMV 84491.
For each Part, mark New, Used, Repaired, Aftermarket or Homemade, and enter the Source/VIN.
When Section II (1) is not applicable
When Section II (1) is not applicable, describe the repairs made in detail.
In box 4 of Section II, enter the Number of Receipts.
Section III. Custom vehicle or street rod
In Section III, Custom Vehicle or Street Rod, the 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.
Check the box for: 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.
Check the box for: 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 in Section III and by signing, you acknowledge and attest to the statements in Section III as your written statement relating to a custom vehicle or street rod; enter the Signature and the Date.
Section IV. Applicant information and signature
In Section IV, Applicant Information and Signature, enter the Date.
The undersigned hereby certifies that the vehicle conforms to Florida and Federal Motor Vehicle Safety Standards.
Under penalties of perjury, you declare that you have read the document and that the facts provided herein are true.
No material information regarding the motor vehicle, motorcycle, or mobile home has been omitted.
Enter the Printed Name of Applicant/Business, Street Address, City, State, Zip and Telephone Number(S), and sign on Signature Of Applicant/Business.
More rules for Form HSMV 84490
Section V is HSMV office use only.
Sources
[1] Form HSMV 84490 (Revised 05-2024), Statement of Builder, State of Florida Department of Highway Safety and Motor Vehicles (the Official source link on this page).