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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)
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