Certificate of Destruction

If you want to prove the destruction of your vehicle, you have to apply for the certificate of destruction. You can apply for this certificate by completing and filing the following form.

Extracted Text for Proper Search

Company Name:
Date:_
Seller's Printed Name:
Sales Tax Reg. No:_

ORIGINAL
 T#
525963284

B#
 66099
Florida Title or Florida Number

DATE OF ISSUE
 11/30/2010
83282125
Body
2D

TYPE OF TOW

PUBL
Model
Copy - Tow/Insurance Company

Make

CHEV
VEHlCLE'JVESSEL DESCRIPTION
ACTUAL MILEAGE
09/30110
For value received, this vehiclelvessel described above is certified, under penallies of perjury, to be free of all liens and is hereby transferred 10:

FIRST ASSIGNMENT
 VehicleNesselldenlification Number
Buyer's Address: _
Street CityState Zip
Seller's Company Name: Seller's Signature:_
NOTE: When a Ce.1ificate of Destruction has been issued, the Dep3J1ment will refuse issuance of any Certificate of Title for that vehicle/vessel.
Seller's Printed Name: Sales Tax Reg. No:_
Date of Sale: Selling Price:
$
 Sales Tax Collected:
$ _

Date of Sale:
Selling Price:
$
 Sales Tax Collected:
$ _

Buyer's Address: ~_
Street CityState Zip
Seller's Company Name: Seller's Signature:_
Buyer's Name:
Buyer's Sales Tax Registration
#: _

CERTIFICATE OF DESTRUCTION

Under penalties of perJury, I hereby certify that the vehicle/vessel described above has been destroyed by crushing, dismantling or cutting into several sections. I understand this form is to be kept in my files for three (3) years. STATE OF FLORIDA
DEPARTMENT OF H1GHWA Y SAFETY AND MOTOR VEHICLES DIVISION OF MOTOR VEHICLES
Neil Kirkman Building· Tallahassee, Florida 32399
CERTIFICATE OF DESTRUCTION
Agent's Printed Name: Agent's Signature:_

ODOMETER STATUS

150,000 MILESBROWARDTEST

OWNER (TOW/INSURANCE COMPANY):
 SAMMY SAMPLE TOW SERVICE
2900 APALACHEE PKWY
TALLAHASSEE. FL 32399
H5MV 82013 (REV. 02106)5
NOTE: Please Print or Type, If buyer has Tax Registration Number, the Selling Price and Sales Tax Collected blocks 3J'e not applicable.
 I

SECOND ASSIGNMENT
 I
For value received, this vehicle/vessel described above is certified, under penalties of perjury, to be free of all liens and is hereby transferred to:
Buyer's Name: Buyer's Sales Tax Registration
#: ._

Original - Issued to Tow/Insurance Company, but transferred and given to new owner
SAMPLE