
STATE OF FLORIDA
DEPARTMENT OF HIGHWAY SAFETY AND MOTOR
VEHICLES DIVISION OF MOTORIST SERVICES
Neil Kirkman Building - Tallahassee, FL 32399-0500
MOTOR VEHICLE TITLE REASSIGNMENT SUPPLEMENT
(Instructions on Reverse Side)
Title No.: State of Issue:
Manufacturer’s Statement or Certificate of Origin
This reassignment is supplement to:
Is th
e title electronic?
Yes No
VEHICLE DESCRIPTION
Vehicle Identification Number Year Make Model Body
REASSIGNMENT INFORMATION
Name of Seller(s)/Agent (Print)
DEALER/AUCTION LICENSE (if applicable)
Selling Price (If Applicable)
Sales Tax Collected (If Applicable)
Sales Tax Reg. No. (If Applicable)
Purchaser and Co-Purchaser's Printed Name(s)
Co-Purchaser’s Address (If applicable)
Auction Name (If applicable)
State of License Date of Auction
ODOMETER DISCLOSURE STATEMENT
WARNI
NG: FEDERAL AND STATE LAW REQUIRE THAT YOU STATE THE ODOMETER MILEAGE IN CONNECTION WITH TRANSFER OF
OWNERSHIP. FAILURE TO COMPLETE OR PROVIDING A FALSE STATEMENT MAY RESULT IN FINES AND/OR IMPRISONMENT.
I/WE STATE THAT THIS 5 OR 6 DIGIT ODOMETER NOW READS,
,
XX (NO TENTHS) MILES,
DATE READ , AND I HEREBY CERTIFY THAT TO THE BEST OF MY KNOWLEDGE THE ODOMETER READING.
CAUTION:
READ CAREFULLY
BEFORE YOU
CHECK A BOX
1 ) REFLECTS ACTUAL MILEAGE
2) IS IN EXCESS OF ITS MECHANICAL LIMITS
3) IS NOT THE ACTUAL MILEAGE.WARNING - ODOMETER DISCREPANCY
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING DOCUMENT
AND THAT THE FACTS STATED IN IT ARE TRUE.
Printed name of seller(s)/Agent
Seller(s)/Agent Signature
Purchaser(s) Printed Name First, Full Middle or Maiden, Last
Co-Purchaser(s) Printed Name First, Full Middle or Maiden, Last
NOTICE: ANY ALTERATION OR ERASURE MAY VOID THIS ASSIGNMENT AND ALL ASSIGNMENTS THAT FOLLOW.
ORIGINAL: SUBMIT WITH APPLICATION FOR TITLE
HSMV 82994 (REV. 04/14) S
COPY: SELLER/DEALER RETAIN IN FILE
Purchaser(s) Signature
Co-Purchaser(s) Signature
Printed name of Co-Seller (If applicable)
Co-Seller Signature (If applicable)