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Suspected or Reported Title and Registration Fraud

Complete the Suspected or Reported Title and Registration Fraud form accurately. Download

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Pursuant to section 319.33(1)(e) , Florida Statutes, it is unlawful to use a fictitious name, give  a false or  fictitious address, 
or make any false statement in any application or affidavit required under the provisions of this chapter or in a bill of 
sale or sworn statement of ownership or otherwise commit a fraud in any application.   Pursuant t
o section 320.02(6 ), Florida Statutes,  any person w ho registers h is or her moto r vehicle by means of false o r 
fraudulent representations made in any application for registration is guilty of a misdemeanor of the second degree, 
punishable as provided in section 775.082 or section 775.083. The Department may demand the return of and may 
cancel any license plate issued based on false or fraudulent representations. 
1.   Complainant/Victim’s Information	 	
Name:	  Driver License Number and Issuing State: 	
City:	 	State:	 	Zip:	 	
E-mail 	Address:	 	Telephone Number:	 	
  Vehicle Information 
Year:	 	Make:	 	Model:	 	
Vehicle Identification Number (VIN):  
State Vehicle Titled In:  Title Number: 
3.  Suspect(s) Information, if known 	
Suspect’s Name:	 	
Known Address:	 	City	:	State	: 	Zip	: 	
Telephone Number	(s)  Home:	 	Work:	 	Cell:	 	
Tag Number(s):	 	
Vehicle Description:	 	
Suspect Description:	 	
If this is an Odometer complaint, please include a picture of the odometer.   HSMV 80122 (Rev. 06/16) S

4.  Certification by  La w E nforc ement  Officer or DMV  Comp lian ce Offic er 	
Nam	e of Law Enforcemen	t Agenc	y frau	d wa	s reporte	d to:	 	
Officer’s Name: 	Teleph	one Nu	mber: 	
Case Number: 	
I, th e unde rsigned , certify  that I have  physica lly inspecte d th e abov e describe d vehicl e an d find  the vehicl e ident ificatio n numbe r (VIN )	 	
on th e vehicle to be  identical to the vehicl e id ent ificat ion number  record ed on  this form.	 	
Ve hicl e Ide ntificat ion Number  Verificat ion:	 	
Curr ent  Odo meter  Reading:	 	,	●xx n o tent hs 	
Sig	nature	 of DMV	 Complian	ce Officer 	or  	 Law	 Enforceme	nt Officer 	
Printe	d Nam	e of DM	V Compl	ianc	e Office	r 	or  	 Law	 Enforceme	nt Officer 	
A. 	Ha s any  forma l complain t bee n made  with any  Law  Enforcemen t Agency  in  connection  with  this  complaint?  	
B. 	Is th e La w  Enforcemen t Agency  conducting  a Moto r Vehicle  Fraud  Investigation ? 	
If yes,  please  attach  a copy  of  the  investigative  report  from  the  Law  Enforcement  Agency  to  th is for m prior  to sending	 	
the  complaint  to the  Department  of Highway  Safety  and Motor  Vehicles.  
Please lis t th e La w Enforcemen t Agency’ s name,  officer’ s name , cas e number , an d contac t information  below: 
C. 	Are you in  posse ssion  of the v ehicle lis ted abov e? 	
If yes , pleas e hav e th e VI N  an d odomete r verifie d by Law  Enforcemen t or  a  DM S Complianc e Office r in  the  space  listed  below.  	
Criminal Case  Incident  Report   Infor mat ional  On ly 	
5.	Com	plain	t/Fraud	 Fac	ts	
If n eeded, use add itional sheets.  N umber  of  add itional pag es attached:	 	
Und er penal ties  of perj ury,  I d ec lare t hat I  have read the forego ing document and t hat the  facts stated in it  are t rue. 
Signature:  Date:   Mail
, Fax , or ema il the complete d for m an d ALL supportin g document s to: Motoris t Services Support , Motor Vehicl e Fra ud

Unit , Roo m C208/MS69, Neil Kirkma n Building , Tallahassee , FL 32399; Phone : 850-617-2 907; FAX : 850-617-3 952; 

Email : 
dmv-en [email protected]

HSMV 80122 (Rev.  06/16) S
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