Application for Towing and Storage Certification of Destruction

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STATE OF FLORIDA 
DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES 
DIVISION OF MOTORIST SERVICES 	
 	SUBMIT THIS FORM TO YOUR LOCAL TAX COLLECTOR OFFICE	 	
www.flhsmv.gov/offices/	 	 	
APPLICATION FOR TOWING AND STORAGE CERTIFICATE OF DESTRUCTION 	 	
1 OWNER / APPLICANT IDENTIFICATION 
Owner’s Name (Tow/Transport Company)   FEID Number  Email Address 
Tow Company's Street Address   City State Zip  
2 VEHICLE/VESSEL DESCRIPTION 
Vehicle/Vessel/Mobile Home Identification Number 
 Year Make  Color  Body Weight 
Previous State of Issue  Length (if applicable)  BHP/CC (if applicable)  Florida Title Number or FL# 
  
3 TYPE OF TOW 	 
 	
   	PUBLIC 	      	PRIVATE 	 
 
4 OWNER / APPLICANT’S CERTIFICATIONS  The Motor Vehicle/Vessel/Mobile Home described above was owned by ________________________________________________,          (Last Registered Owner of Record)  with a recorded lien to ___________________________________________________________________ and has been lawfully sold to      	(Registered Lienholder of Record) 	 __________________________________________________ on ___________________, in a Non-Judicial State for enforcement       (Towing/Transport Company)            (Date)  of a lien for towing and storage charges justly owing and unpaid since _____________________.  Having followed all provisions of                        (Impound Date) 
Section 713.78 or 713.785, Florida Statutes, I understand that no sales tax is due and I certify that the vehicle/vessel/mobile home 
identification number shown on this application has been physically inspected by me, and is identical to the vehicle/vessel/mobile home 
identification number shown on the motor vehicle/vessel/mobile home. 
 	I have made a diligent search and inquiry as to the registered owner, lienholder and insurance company without beneficial results.   
A good faith effort has been made as defined in Section 713.78 or 713.785, Florida Statutes. 
 I hereby certify that ownership information was unavailable within the seven (7) day period required by law and hereby certify that law 
enforcement was notified by this company after seven (7) days.  Attached is a copy of the notice sent to law enforcement and a copy 
of the returned receipt showing the date or a copy of the acknowledged hand-delivered receipt signed by the law enforcement 
agency. 
 I hereby certify that the owner of the motor vehicle/vessel/mobile home described above has transferred the attached title over to our 
tow/transport company in lieu of paying the towing and storage charges.  We understand this process will permanently relinquish our 
company's ability to place a wrecker operator's lien against the owner of this vehicle/vessel/mobile home. 
 	If applying for a "duplicate" Certificate of Destruction, check this block: 	 I hereby certify that this company is the owner of the motor vehicle/vessel/mobile home described above and a Certificate of 
Destruction was issued in the company's name on ________________.  I hereby certify that the Certificate of Destruction has been 
lost or destroyed and request a duplicate Certificate of Destruction be issued.  If the lost or missing Certificate of Destruction is located, 
it will be returned to the Department.	
 	 	
5 MOTOR VEHICLE ODOMETER DECLARATION 
I/WE STATE THAT THIS 	 5 OR	 	 6 DIGIT ODOMETER NOW READS	,	 .XX (NO TENTHS) MILES DATE READ	 	
________/________/________, AND I/WE HEREBY CERTIFY THAT TO THE BEST OF MY KNOWLEDGE THE ODOMETER READING IS:  
 
    1.  reflects ACTUAL MILEAGE.   2.  is IN EXCESS OF ITS MECHANICAL LIMITS.     3.  is NOT THE ACTUAL MILEAGE.  
                                WARNING – ODOMETER DISCREPANCY 
 
6 OWNER / APPLICANT’S SIGNATURE	 	In consideration of the foregoing and the attached evidence of ownership to the motor vehicle/vessel/mobile home described above, I 
request that the Certificate of Destruction be issued in the towing/transport company's name. 
 I hereby swear or affirm, under penalty of perjury, that this company owns the above-described motor vehicle/vessel/mobile home and I 
affirm under penalty of perjury that all of the foregoing information is true and correct.  I further agree to defend the title against all claims.  I 
further certify that I have made a physical inspection of the vehicle (when applicable) and have recorded the vehicle identification number, 
other identification information and the odometer reading in the spaces provided on this form. 
 Name of Tow/Transport Company _____________________________________________________________________________  
Signature of Agent _____________________________ Printed Name of Agent: _________________________________________   HSMV 82012 (Rev. 06/13) S     www.flhsmv.gov

I hereby certify that I have made inquiry in the Florida Crime Information Center (FCIC) and the National Crime Information Center 
  (NCIC) and find that the identification number for the vessel or mobile home	
 shown above has not been reported as stolen. 	 Agency Name: ___________________________________________________________    Badge Number:  ______________________	 	 Law Enforcement 
Officer's Signature:  _________________________________ Printed Name:  ___________________________________________ 
  	
TOWING AND STORAGE CHECKLIST FOR CERTIFICATE OF DESTRUCTION	 	You should review section 713.78 and 713.785, Florida Statutes, or DMS Procedure TL-26 prior to making application for a Certificate of Destruction. 
 
FLORIDA RECORD	:      	OUT -OF-STATE