Application for Salvage Title and Certificate of Destruction

Requesting a salvage title and certificate of destruction for a motor vehicle requires the completion of the following form by the lienholder. Complete the form and submit it along with any necessary supporting documents.

Extracted Text for Proper Search

STATE OF FLORIDA 
DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES 
DIVISION OF MOTORIST SERVICES 	
 
 
 	
LIEN SATISFACTION 	 
 
 	
Check One:  Motor Vehicle  Mobile Home  Off-Highway Vehicle   Vessel 	 
Title Number: Vehicle/Vessel 
Identification Number: 
Year: Make/Manufacturer:  Body Type:  Color: 
Registered Owner(s)	 
Name(s): 	(Last Name First)	  Date of Issue: 	
Street Address: 
City: State: Zip: 
FIRST LIENHOLDER Lien Date:                                             	(month-day-year)	Lien Satisfaction Date:                                         	(month-day-year)	
Name: 
Street Address: 
City: State: Zip: 
SECOND LIENHOLDER Lien Date:                                             	(month-day-year)	Lien Satisfaction Date:                                         	(month-day-year)	
Name: 
Street Address: 
City: State: Zip 
 
LIEN SATISFACTION:  THE UNDERSIGNED HOLDER OF ABOVE DESCRIBED LIEN(S) ON THE MOTOR VEHICLE, MOBILE HOME, OFF HIGHWAY VEHICLE OR 
VESSEL DESCRIBED HEREON ACKNOWLEDGES SATISFACTION THEREOF. 
 NOTE:    IF THE FIRST AND SECOND LIENHOLDER ARE THE SAME PERSON OR ENTITY AND ONLY ONE LIEN IS BEING SATISFIED, DO NOT PERFORATE 
OR USE A PAID STAMP.  COMPLETE THE APPROPRIATE SPACE BELOW FOR THE LIEN THAT IS BEING SATISFIED. 
 UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FORGOING DOCUMENT AND THAT THE FACTS 
IN IT ARE TRUE. 
 
First Lienholder Name: 
Print Title of Authorized Agent for Lienholder: 
Signature of Authorized Agent For Lienholder: 
 
Second Lienholder Name: 
Print Title of Authorized Agent for Lienholder: 
Signature of Authorized Agent For Lienholder: 
 NOTE:   LIENHOLDER MUST COMPLETE ALL APPLICABLE SECTIONS OF THIS FORM INCLUDING DESCRIPTION OF THE MOTOR VEHICLE, MOBILE HOME 
OR VESSEL, NAME AND ADDRESS OF THE OWNER(S), AND NAME AND ADDRESS OF THE LIENHOLDER.  THE DATE OF LIEN MUST BE THE 
SAME AS THAT SHOWN ON THE TITLE CERTIFICATE.  THE LIEN SATISFACTION MUST BE PROPERLY EXECUTED AND MAILED TO DEPARTMENT 
OF HIGHWAY SAFETY AND MOTOR VEHICLES, DIVISION OF MOTORIST SERVICES, NEIL KIRKMAN BUILDING, 2900 APALACHEE PARKWAY, 
TALLAHASSEE, FLORIDA 32399, BY THE LIENHOLDER WITHIN TEN (10) DAYS AFTER FINAL PAYMENT FOR MOTOR VEHICLES, MOBILE HOMES, 
AND OFF-HIGHWAY VEHICLES AND WITHIN THIRTY (30) DAYS FOR VESSELS. 
 
HSMV 82260 (REV.07/11)S                 www.flhsmv.gov