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Florida Department of Highway Safety and Motor Vehicles Champs License Plate Request

In the case of wanting to request license plates the State of Florida, the following form has to be completed and submitted.

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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 DUPLICATE OR LOST IN TRANSIT/REASSIGNMENT FOR A 
MOTOR VEHICLE, MOBILE HOME OR VESSEL TITLE CERTIFICATE  	
 	1 	TYPE OF APPLICATION	 	 
 	  VEHICLE/VESSEL       	         	DUPLICATE:  	 	  	    VEHICLE/VESSEL   	          	  LOST IN TRANSIT:	 	
 	VEHICLE/VESSEL  DUPLICATE WITH TRANSFER:  	(Both parties must be present for this transaction)  	 	
 AND   NOTE: W hen joint ownership, please indicate if “or”  or	 	 OR 	  	
“and”  is to be shown on the title when issued.   If neither box is checked, the 
title  will be issued with “and”.	 	
           	(Fee Required)  	NOTE: No fee required if vehicle application 	
 LOST	  	             	STOLEN	  	 	is made within 180 days from last title 	
Damaged	 (Certificate of Title must be s ubmitted) 	 	issuance date and has been lost in mailing.  	
NOTE: An indication of lost, stolen or damaged is required	. 	   	 OWNER’S NAME 	(Last, First, Middle Initial)	 	 Owner’s E-Mail Address  	 PURCHASER’S NAME 	(Last, First, Middle Initial)	 	 Purchaser’s E -Mail Address  	
 CO-OWNER’S NAME 	(Last, First, Middle Initial)	 	 Co -Owner’s E -Mail Address  	 CO-PURCHASER’S	 NAME	 (Last, First, Middle Initial)	 	 Co -Purchaser’s E -Mail Address  	
 OWNER’S MAILING ADDRESS  
 	 PURCHASER’S MAILING ADDRESS  	
 CITY 	 STATE 	 ZIP 	 CITY  	 STATE 	 ZIP 	
CAUTION:	 IF ADDRESS DIFFERS FROM DMV RECORDS,   
ADDRESS VERIFICATION MUST BE SUBMITTED	 	
 DATE OF BIRTH  	 PURCHASER’S DL/ID #  	 CO-PURCHASER’S DL/ID#  	
2 	APPLICATION FOR DUPLICATE IS MADE BY:  	 
 	 Owner	 	
LIENHOLDER  DATE OF LIEN 
 	
MOTOR VEHICLE MOBILE HOME OR RECREATIONAL VEHICLE DEALER/  
AUCTION LICENSE NUMBER (	DEALER/AUCTION LICENSE NUMBER DOES NOT APPLY TO VESSELS:  	 LIENHOLDER OR DEALER/AUCTION NAME:   ADDRESS:                                                                                            CITY:                                                                  ST ATE:                   ZIP:	 	
3 	MOTOR VEHICLE, MOBILE HOME OR VESSEL DESCRIPTION  	Vehicle/Vessel Identification Number	 	Make/Manufacturer	 	Year	 	Body	 	Color	 	License Plate or Vess	el Registration Number	 	Florida Title Number	 	 
 	
4 	VEHICLE USAGE/BRANDS	 	    
 SHORT TERM LEASE 
 
REPLICA  	   
 LONG TERM LEASE  
 
KIT CAR  	   
 POLICE VEHICLE  
 
REB UILT  	   
 PRIVATE USE  
 
ASSEMBLED FROM PARTS 	 TAXI  	   
 FLOOD  
 
MANUFACTURER’S BUY BACK  	
5 	LIENHOLDER INFORMATION	 	If no lien, Print “None”	 	 	 FEID #	   	DL# & Sex and Date of Birth   	DMV Account #   	 	Date of Lien	 	Lienholder Name	 	
Lienholder E-Mail Address   Lienholder Mailing Address  City  State Zip 	
 If Lienholder authorizes the Department to send title to the owner, check box and countersign.  	 	
If this box is not checked, title will be mailed to the first lienholder. 	(DOES NOT APPLY TO VESSELS)   	(Signature of Lienholders Representative)
 	 	6 	APPLICATION ATTESTMENT/SIGNATURES AND ODOMETER DECLARATION/DISCLOSURE	 	WARNING:  Federal and state law require that you state the mileage in connection with an application for Certificate of Title.  Providing a false statement may result in fines or imprisonment.  	 
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 M	Y/OUR KNOWLEDGE THE ODOMETER READING:	 	 	CAUTION: READ CAREFULLY BEFORE YOU CHECK A BOX	 	       1. REFLECTS ACTUAL MILEAGE.         2. IS IN EXCESS OF ITS MECHANICAL LIMITS.  (EXCESS OF ITS MECHANICAL LIMITS APPLIES TO 5 DIGIT ODOMETERS)        3. IS NOT THE 	ACTUAL MILEAGE.  	WARNING	 - ODOMETER DISCREPANCY	 	
  I CERTIFY THAT THE MOTOR VEHICLE/VESSEL DESCRIBED ABOVE WILL NOT BE OPERATED ON THE STREETS AND HIGHWAYS/WATERWAYS OF	 	THIS STATE AND NO FLORIDA LICENSE PLATE HAS BEEN TRANSFERRED TO OR PURCHASED FOR THIS MOTOR VEHICLE. 	 I am/we are the owner(s), lienholder(s), and am legally authorized to apply for and receive the Duplicate Certificate of Title.  I/we further agree to 
indemnify the Department and defend the Certificate of Title against all  actions or claims by any person.  
 UNDER PENALTIES OF PERJURY, I/WE DECLARE THAT I/WE HAVE READ THE FOREGOING DOCUMENT AND THAT THE  FACTS STATED IN IT ARE TRUE.	 	IF APPLICABLE, I ATTEST TO HAVING   
ACQUIRED THE MOTOR VEHICLE, MOBILE   
HOME OR VESSEL DESCRIBE	D ABOVE BY:	 	 PURCHASE 	 GIFT 	 INHERITANCE  	 COURT ORDER  Date Sold
  Selling Price $  	
 Signature of 
Purchaser:  	   _______________________________________________________________________	 	
 Print ed Name   
of Purchaser:   ___	____________________________________________________________________	 	 Signature of  Co-Purchaser:  	_____________________________________________________________________	 	
 Printed Name of  Co-Purchaser’s:  	_________________________	____________________________________________	 	 Signature of Seller/  Owner/Lienholder:  	__________________________________________________________________	 	
 Printed Name of  Seller/ Owner/Lienholder:  	_________________________________________________________	_____	 	 Signature of 
Co -Owner:   ________________________________________________________________________  
 	
 Printed Name of 
Co -Owner:   __________________________________________________________________________	 	
7 	FOR FLORIDA DMV OR TAX COLLECTOR/LICENSE PLA	TE AGENCY USE ONLY	 	
 Duplicate authorization 	        	verification completed	 	Signature	 	Printed Name	 	County	 	Agency #	 	Date Completed	 	
 HSMV 82101 (Rev.  06 /11) S                               	www.flhsmv.gov

Instructions for Completing the Form HSMV 82101 	 	Section 1 – Type of Application	 
  Vehicle/vessel duplicate –  This box indicates you want to order a replacement title.   Also, check the appropriate box indicating 
lost, stolen or damaged.  A fee is required for this type of application.    	
 	
 Vehicle/vessel lost in transit –  This box indicates you have ordered a title and at least 20 days have passed and you have not 
received the title.  No fee is required if  the application is made within 180 days of  the last title issuance which was lost in the mail.  
Fees are charged for duplicates or lost in transit requests  after more than 180 days from the previous issuance.   
 
 Vehicle/vessel duplicate with transfer –  This box should be checked if you need to or der a duplicate title and immediately transfer  
it to another owner.  Both parties must  be present and have photo identification.  A po wer of attorney may not be used, except when a 
total loss from an insurance company is being paid.   
 Address Change Directions – For an individual owner or lienholder, if the address differs from the address on the department’s 
record, one of the following must be submitted:   
 	o Driver license    
o  Paid receipt for utility or telephone service 
o  Proof of homestead exemption    
o  Paid contract or turn-on order for utility service 
o  Rental or lease contract agreement 
o  Current year motor vehicle, mobile hom e or vessel certificate of registration 
o  Copy of insurance policy for motor vehicle, mobile home or vessel 
o Other documentary evidenc e that provides independent	
 proof of address change 	
 Section 2 – Application for Duplicate is made by:	  Check the appropriate box to indicate who  is applying for the duplicate.  Provide 
name, address and, if you are a dealer,  provide your dealer license number.   	
 	Section 3 – Motor Vehicle, Mobile Home or Vessel Description:  	Complete all applicable information.  The purchaser must provide a 
license plate or vehicle registration number if you are reques ting a duplicate with transfer unless the vehicle or vessel will  not be operated 
on Florida highways or waterways.  If the vehicle or vessel will  not be operated on Florida highways or waterways, the box in section 6 
must be checked stating such.   	
 	Section 4 – Vehicle Usage/Brands:	  Check the appropriate box to indicate how the vehicle will be used.  If the vehicle is your personal 
vehicle, private use should be checked.   	
 	Section 5 – Lienholder Information:  	If there is no lienholder, the word none should be  indicated in the first box.  If a lien is being added 
to the record at the time the application is su bmitted, all information should be completed.   	
 	
Section 6 – Application Attestment/Signatur es and Odometer Declarations/Disclosures:  	Check the box to indicate whether the 
vehicle has a five or six-digit odometer and enter the odometer  reading from the vehicle.  The vehicle is exempt from the odome ter 
requirement if it is 10 years old or older.   	
 
  Enter the odometer reading from the motor vehicle, unless  the motor vehicle is exempt from the odometer requirement.  
 If there is any reason to doubt the odomet er reading does not accurately reflect “actual” mileage, check the box to indicate 
“not actual mileage.”  If the vehicle has  more than 99,999 on the odometer reading and  it is a 5-digit odometer, the box “in 
excess of mechanical limits” must be checked.   
  If a duplicate with transfer is requested,  enter the date of sale and the selling price.  The appropriate box indicating the t ype 
of transaction must also be checked.  If the vehicle/vessel wi ll not be operated on Florida highways or waterways, the box 
must be checked.   
  The appropriate customer(s) must sign and prin t their names in the spaces provided.   
 	
Fees and Addresses:	 	 
Fees are located on our website http://www3.flhsmv.gov/DMV/Proc/Fees/Fees-01.PDF	.  Addresses for all Florida county 
tax collectors’ offices are located on our website at:  http://www.flhsmv.gov/offices	
.  Some county agencies offer a fast title 
service for an additional fee. 
  The applicant must provide proof of identity (driver license, iden tification card, etc.) with their completed application. This 	
includes proof of identity for any individual signing as an authorized agent for a company/business, when applicable. This 
condition does not apply to a Florida licensed motor vehicle, mobile home or recreational dealer, a Florida licensed motor	 
vehicle auction, a licensed insurance company, a lienholde r, a Florida vessel dealer or their authorized agent.	
 
 
Check your local phone book government pages or visi t the following website for current mailing addresses: 
http://www.flhsmv.gov/offices/	
 	 
THIS FORM IS A COMBINATION OF FORMS HSMV 82101, 82055 AND 87009. 	
 	HSMV 82101 (Rev. 06/11) S      www.flhsmv.gov
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