Application for Notice of Lien and Reassignment of Lien or Notice to First Lienholder of Subsequent Lien

Completing the following application form and submitting it to the local tax collector’s office is necessary for applying for a notice of lien.

Extracted Text for Proper Search

STATE OF FLORIDA 
DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEH ICLES – DIVISION OF MOTORIST SERVICES 	
 
 	
SUBMIT THIS FORM TO YOUR LOCAL TAX COLLECTOR OFFICE  www.flhsmv.gov/offices/	
 	 	
APPLICATION FOR NOTICE OF LIEN  / REASSIGNMENT OF LIEN OR 
NOTICE TO FIRST LIENHOLD ER OF SUBSEQUENT LIEN 	
   	
SECTIONS 1 AND 2 SHOULD BE COMPLETED IF ADDING AN ORIGINAL LIEN. 	  MOTOR VEHICLE    	 MOBILE HOME 	 SECTIONS 1 AND 3 SHOULD BE COMPLETED IF REASSIGNING A LIEN. 	 	
SECTIONS 1, 2 AND 4 SHOULD BE COMPLETED IF ADDING A SUBSEQUENT LIEN.  	  OFF-HWY VEHICLE    	 VESSEL 	 	
1) DESCRIPTION OF MOTOR VEHICLE, MOBILE HOME, OFF-HIGHWAY VEHICLE  OR VESSEL DESCRIPTION 
IDENTIFICATION NUMBER  VESSEL REGISTRATION NUMBER 
MAKE/MANUFACTURERYEAR MODEL  WT.-LGTH.-BHP 
COLOR  TYPE  USE 
CERTIFICATE OF TITLE NUMBER  PREVIOUS ISSUE DATE LICENSE PLATE NUMBER 	
2) NOTICE OF LIEN - LIENHOLDER INFORMATION	 	
 FEID#      	  Driver License Number and Sex and Date of Birth      	  DMV Account# 	
DATE OF LIEN LIENHOLDER NAME  LIENHOLDER’S E-MAIL ADDRESS 
LIENHOLDER ADDRESS 
  CITY                                                                             STATE  ZIP CODE 
 	
   Electronic title and lien parti
cipant (Electronic title only). 	 
 	
   If the lienholder authorizes the depar tment to send title to the owner, ____________________________________________________ _________ 
check box and countersign.   (DOES NOT APPLY TO VESSELS)  Signature of Lienholder’s Representative 	
 One of the following boxes must be	 checked. 	
  A security agreement, retain title contract, conditional bill of sale, chattel mortgage  or other similar instrument was executed prior	 to the filing of this 
notice of lien. 	
 	
  This notice of lien is being filed before	 a security agreement, retain title c ontract, conditional bill of sale, chatte l mortgage or other similar instrument 
is being executed. 	
 UNDER PENALTIES OF PERJURY, I (WE) DECLARE THAT I (WE) HAVE READ THE FOREGOING         	 Date	_____________________________ 
DOCUMENT AND THAT THE FACTS STATED IN IT ARE TRUE.  	
 __________________________________________________________   ______________________________________________________________ 
                             	Signature of Registered Owner 	  	                                        Signature of Registered Co-Owner 	 
__________________________________________________________   ______________________________________________________________ 	
               Print Name of Registered Owner	       	Print Name of Registered Co-Owner	 
 
__________________________________________________________   ______________________________________________________________ 
                                  	
Street Address (Owner)	                                         	Street Address (Co-Owner)	 
 
__________________________________________________________   ______________________________________________________________ 
City                                                                State               Zip Code                     City                                                   State                        Zip Code 	
 	
3) APPLICATION FOR REASSIGNMENT OF LIEN 	 The undersigned hereby represents that they are the assignee of that certain 	 first or 	 second lien dated the _________________ day 	 of (Month/Year) __________________________, covering the motor vehicle, mob ile home, off-highway vehicle or vessel described in section   one of this form and request that the Florida Certificat e of Title, which was issued on (Month/Day/Year) ______________________ ______,  be re-issued to show such lien as now being held by the undersigned applicant and represents that on this date there is a balance as principal 
still due and unpaid. 
 UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FORE GOING DOCUMENT AND THAT THE FACTS STATED IN IT ARE TRUE.  ________________________________________________________   By __________________________________________________________ 
  Name of Assignee (New Lienholder)  Signature of Lienholder's Representative 
                                                                                                                Title    _________________________________________________________  
 
Address _________________________________________________ City _________________________ State _________ Zip Code __________  UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FORE GOING DOCUMENT AND THAT THE FACTS STATED IN IT ARE TRUE.  ________________________________________________________   By __________________________________________________________ 
 Name of Assignor  (Lienholder currently shown on Title)  Signature of Lienholder's Representative 
                                                                                                                Title    _________________________________________________________   HSMV 82139 (Rev. 06/11) S	 www.flhsmv.gov

4) NOTICE TO FIRST LIENHOLDER OF SUBSEQUENT LIEN 	
 	
Date _____________________________ 	
 	
To:  _____________________________________________________________________________________________ 	
First Lienholder 	
 
Address:  ________________________________________________________________________________________ 
 
City and State:  ______________________________________________________ Zip Code _____________________ 
 
You are the first lienholder on Title Number __________________ covering the motor vehicle, mobile home, off-highway 
vehicle or vessel described on the reverse of this form, which  is recorded in the office of the DIVISION OF MOTORIST 
SERVICES in Tallahassee, Florida.   FLORIDA STATUTES REQUIRE THE FIRST LIENHOLDER TO SUBMIT THE 
CERTIFICATE OF TITLE TO THE DIVISION OF MOTORIST  SERVICES WITHIN TEN (10) DAYS AFTER RECEIPT OF 
THIS NOTICE, UNLESS THE DMV DATABASE  REFLECTS AN ELECTRONIC TITLE.  This is to advise you that I have 
this date placed an additional lien on the above described motor vehi cle, vessel, off-highway vehicle or mobile home with: 
 
________________________________________________________________________________________________ 
Name of Subsequent Lienholder                                                                           Lienholders E-mail Address 
 
________________________________________________________________________________________________ 
Address 
 
________________________________________________________________________________________________ 
 City                                                                                         State           Zip Code 
Please forward the above mentioned Certificate of Title with this request attached, if applicable, to the DIVISION OF 
MOTORIST SERVICES, at Tallahassee, Florida, for the  purpose of recording the subsequent lien thereon.  When the 
subsequent lien is recorded, the Division of Mo torist Services will mail a Certificate of Title to you, if applicable, as first 
lienholder. 
 
UNDER PENALTIES OF PERJURY, I DECLARE THAT  I HAVE READ THE FOREGOING DOCUMENT AND THAT 
THE FACTS STATED IN IT ARE TRUE. 
 
 
Signed:  _________________________________________________________________________________________ 
                                                 Signature of Owner                             Signature of Co-Owner 
 
Name:  __________________________________________________________________________________________ 
           Print or Type                   Print or Type	 
 
 	
INSTRUCTIONS WHEN USING SECTION 4 OF THIS FORM: 
Prepare in duplicate and send a copy of this form by registered or certified mail with the returned receipt requested to the 
first lienholder, as shown on the DMS database record.  Submit t he original copy of the form to a county tax collector’s 
office with the return receipt signed by the first lienholder  and the lien recording fee provided by section 328.14(6), Florida  
Statutes, for vessels, by section 319.32(1) and (2) (a), Fl orida Statutes, for motor vehicles and mobile homes and 
sections 317.0006(5) (a), & 317.0007(1), Florida Statutes, for off-highway vehicles. 
 
Notice to the First Lienholder:   If you fail, neglect, or refuse to forward the certificate of title to the department  
within 10 days from the date of the owner’s request, the department, on the written request of the subsequent lienholder 
or an assignee thereof, shall make written demand to you for the return of such certificate of title for  
the notation of the second or  subsequent lien or encumbrance. 
 
THIS FORM IS A COMBINATION OF FORMS HSMV 82139, HSMV 82140, HS MV 82365 AND HSMV 87004. 
 
Check your local phone book government pages or visit the following website for current mailing 
addresses : http://www.flhsmv.gov/offices/	
 	
 
 
HSMV 82139 (Rev. 06/11) S	
  www.flhsmv.gov