Application and Claim To Recover Compensation from the Mobile Home and Recreational Vehicle Trust Fund
Applying for a compensation from the mobile home and recreational vehicle trust fund requires the use of the following application form. Complete the form and submit it along with all of the required supporting documents.
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STATE OF FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES DIVISION OF MOTORIST SERVICES APPLICATION AND CLAIM TO RECOVER COMPENSATION FROM THE MOBILE HOME AND RECREATIONAL VEHICLE TRUST FUND INSTRUCTIONS: Type or legibly print all information , except signatures. In order to process this application , all questions, including the sworn statement, must be properly completed. Please complete the appropriate form for either Unsatisfied Judgment or Bankruptcy. All documents supporting the claim must be submitted with the application in order to properly access the claim for approval or disapproval. The completed application and supporting documents are to be forwarded to: Claims Administrator Division of Motor ist Services 2900 Apalach ee Parkway, MS-61 Tallahassee, Florida 32399 Pursuant to section 320.781, Florida Statutes, I hereby make application and submit the required documentation, under oath, for compensation of an unsatisfied judgment or unsatisfied claim against a mobile home or recreational vehicle dealer or broker and/or surety. The maxi mum claim that can be paid under the trust find is $25,000. Name of Claimant Residence address ( ) City, State and Zip Code Home telephone number ( ) Business telephone number Social Security number of Claimant Date signed Signature of Claimant HSMV-84019 (Rev. 01 /11) DESCRIPTION OF UNIT Note: If the transaction resulting in this claim arose out of a consignment sale rather than a purchase, use the date of the consignment transaction. Date of purchase/consignment Unit/Vehicle Identification Number (VIN) Make of unit Model/Year of unit Color of unit DEALER/BROKER INFORMATION Dealer/Broke r Name License Number Address of Dealer/Broker City, State and Zip Code SURETY COMPANY INFORMATION Note: Be sure that the named surety bond was the correct bond in effect at the time of the transaction, which is the subject of this claim. Name of Surety Company Surety Number Address of Dealer/Broker City, State and Zip Code HSMV -84019 (Rev. 01/11) UNSATISFIED JUDGMENT If your application for claim is based on an unsatisfied final judgment against a mobile home or recreational vehicle dealer or broker or its surety jointly and severally, or against the mobile home dealer or broker only, where the court found that the surety was not liable due to prior payment of valid claims against the bond in an amount equal to, or greater than, the face amount of the applicable bond; or , if your claim is based on an unsatisfied judgment against the surety of the mobile home or recreational vehicle dealer or broker, the following documentation must accompany this application. 1. A copy of the judgment. Does the judgment contain?: a. a list of damages, b. a determination of the liability of the surety company, c. costs, d. attorney fees. 2. Evidence that Judgment or Lien has been recorded with the clerk' s office. 3. A copy of the purchase agreement or consignment agreement for the vehicle. 4. Documentation that substantiates the judgment against the dealer/broker is unsatisfied. 5. Docum entation of the amount or value of recovery made thus far against the liable party. 6. An attestment to the amount that may be realized from the sale or assets of the liable party. 7. Certificate, statement, or document that claimant has made a good faith effort to collect from the judgment. (Attach additional sheet if necessary) 8. An assignment by claimant or rights, title or interest in the unsatisfied judgment and judgment lien to the Department of Highway Safety and Motor Vehicles. Assignment of Judgment, HSMV 84027, has been executed and is attached. Note: Claims containing incomplete documentation cannot be processed until the required documentation has been submitted. Please include any additional information that may be of assistance to this office in successfully processing your claim. HSMV-84019 (Rev. 01/11) BANKRUPTCY If your application for claim is based on a lawsuit which has been stayed or discharged as a result of the filing for reorganization or discharge of bankruptcy by the dealer or broker, and judgment against the surety is not possible because of the bankruptcy or liquidation of the surety, or because the surety has been fou nd by the court not to be liable due to the prior payment of valid claims against the bond in an amount equal to, or greater than, the face amount of the applicable bond, the following information must be completed and the requested documentation must acco mpany this application. Indicate type of Bankruptcy: Liquidation Rehabilitation (Reorganization) 1. Assignment of Claim/Suit, HSMV 84026 has been executed and attached. 2. Copy of the lawsuit filed by claimant against the dealer and/or surety company along with a copy of all pleadings in the case. 3. Copy of the order of the bankruptcy court staying or discharging the proceeding. 4. Documentation that the surety company is not liable and the reason. 5. True copies of all sales documents, purchase agreements, notices, service repair orders and any other documentation pertaining to the case. 6. Actual monetary amount needed to reimburse or compensate the claimant, supported by documentation. 7. Allegations setting forth the facts of the complaint. (Attach additional sheets, if necessary) Note: Claims containing incomplete documentation cannot be processed until the required documentation has been submitted. Please include any additional information that may be of assistance to this office in successfully processing your claim. HSMV -84019 (Rev. 01/11) STATEMENT UNDER OATH I hereby swear or affirm that the information and doc umentation submitted as part of this application are true and correct and are provided as requested without reservation. Date Signed Signature Printed or Typed Name of Claimant Sworn to or affirmed and subscribed before me this day of , My Commission Expires: NOTARY PUBLIC State of Florida at Large Personally Known Produced Identification HSMV -84019 (Rev. 01/11)Relevant article from our knowledge database
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