Complete the Suspected or Reported Title and Registration Fraud form accurately. Download
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STATE OF FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES DIVISION OF MOTOR VEHICLES SUSPECTED or REPORTED TITLE and REGIST RATION FRAUD 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: Address: City: State: Zip: E-mail Address: Telephone Number: 2. 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? YES NO B. Is th e La w Enforcemen t Agency conducting a Moto r Vehicle Fraud Investigation ? YES NO 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? YES NO 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) SRelevant article from our knowledge database
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