STATE OF FLORIDA

DEPARTMENT
DEPARTMENT OF
OF HIGHWAY
HIGHWAY SAFETY
SAFETY AND
AND MOTOR
MOTOR VEHICLES
VEHICLES-– DEVISIONOF
DEVISIONOF MOTORIST
MOTORIST SERVICES
SERVICES

SUBMIT THIS FORM TO YOUR LOCAL TAX COLLECTOR OFFICE

www.flhsmv.gov/offices/
flh s/

POWER OF ATTORNEY FOR A MOTOR VEHICLE, MOBILE HOME OR VESSEL

(Date)
(Date)

I/We
I/We hereby
hereb_ name
name and
and appoint,
ap om , to bee my/our
my/our
(Full
Ir-
Legibly Printed Name is Required)
I I

lawful
lctVVIUI attorney-in-fact,
ctllUI 11ty-111-1ctl;l , to LU act
ctl,;L for
IUI me/us,
I I lt/u::, , in
111 applying
Clt,.JtJIYII 1y for
IUI an
di I original
UI 1y11 lctl orUI duplicate
UUf,Jlll,;ctlt certificate
l,;tl lllll,;ctlt of UI title,
l l l l t , to
LU register,
I ty1::>u::1 , transfer
LI ell l::>ltl title,
llllt ,
or
UI record
I t(.;UI U act lien
l l t l I to
LU the
LI I t motor
11 IULUI vehicle,
Vtl 11(.;lt, mobile
11 IUUllt homeI IUI I I t or
UI vessel
vt::,::,t1 described
ut::, t,; 1 IUtU below,
UtlUVV, and di IU toLU print
f,-'I 11 ll my/our
111y,uu1 name I ldl I I t and
di IU sign
::,1y1 I their
ll l t l l
name,
lldlllt: , in
Ill my/our
11Iy,uuI behalf.
Ut:lldll. My IvIy attorney-in-fact
dLLU11I,:,y-11I-Id<.;L can l;dll also
aI::,u do
uu alldll things
Llllll!:j::, necessary
11,:,1;,:,::,::,aIy to
LU the
LIit: application
dfJfJlll;dLIUII or UI any
dllY other
ULllt:I related
lt:ldLt:U
instrument
11I::,LIUlllt:IIL and
dllU to LU bind
UIIIU me/us
1111., in as sufficient a manner as I/we myself/ourselves could do, were I/we personally present
and signing the same.
With
VVILII full
IUII power
fJUVVt:I of
UI substitution
::,uu::,LILULIUII and
dllU revocation,
lt:VUl;dLIUII , I/we
1/VVt: hereby
11,:,1 ratify
ratify and
and confirm
confirm whatever
whatever my/our
my/our said
said attorney-in-fact
attorney-in-fact may
may
lawfully do or cause to be done in the virtue hereof.

CHECK
CHECK ONE:
ONE:
□ Motor
tor Vehicle
Vehicle
□ Mobile
bile Home
Hom
□ Vesselel
Year
Year Make/Manufacturer
Make/Manufacturer Body
Body Type
ype Title
Ille Number
Number

Vehicle/Vessel
1cleNessel Identification
ldent1ficat1on Number

NOTICE TO OWNER(S): COMPLETE THIS FORM IN ITS ENTIRETY PRIOR TO SIGNING.

UNDER
UNDER PENALTIES
PENAL TIES OF
OF PERJURY,
PERJURY. I/WE
I/WE DECLARE
DECLARE THAT
THAT I/WE
I/WE HAVE
HAVE READ
READ THE
THE FOREGOING
FOREGOING DOCUMENT
DOCUMENT AND
AND
THAT
THAT THE
THE FACTS
FACTS STATED
STATED IN
IN IT
IT ARE
ARE TRUE.
TRUE.

(Signature
(Signal of,f Owner
Own !r "Grantor”)
antor") (Legibly
(Legibly Printed
Pnnted Name
N of,f Owner
n r "Grantor")
"Gr ntor")

(Driver
(Dnv r License,
Lie nse Identification
ldont1ficat1on Card
Card or
or FEID
FEID Number
Num for
, r Owner)
Own !r) (Date
(Dato of
of Birth
811 forr Owner,
Own !r if applicable)
1pphcable)

(Owner’s
(Own r s Address
A Jress)) (City)
(City) State)
State) (Zip)
(Zip)

(Signature
(Signal of,f Co-Owner
Co-O n !r "Grantor,”
antor, ifIf applicable)
apphcable) (Legibly
(Legibly Printed
Pr nted Name
Name of Co-Owner
J- Own r "Grantor,"
ntor • if1f applicable)
apphcable)

(Driver
(Dnv r License,
Lie nse Identification
Id nt1ficat1on Card
Card or
or FEID
FEID Number
Numt for
,r Co-Owner)
Co Own !r) (Date
(Dat of
of Birth
811 forr Co-Owner,
Co-O n !r if applicable)
pphcabl )

((Co-Owner’
Co-Own .r s
s Address
ress)) (Cit y)
(City) ((State)
State) (Zip)
(Zip)

This
I 111::, non-secure
11u11-::,,:,1.,uI t, power
fJUVVt:I ofUI attorney
dLLUll lt:Y form IUll 11 may
11 ldY beu,:, used
u::,,:,u when
VVllt:11 andll individual
II IUIVIUUdl or UI entity
t:IILILY appointed
dfJfJUII ILt:U as LI'"' attorney-in-fact
a::, the dLLUll lt:y-11I-ldl.,L will VVIII
be
u,:, completing
l;UI I lfJlt:Lll l!:j the
LI It: odometer
UUUI I lt:Lt:I disclosure
uI::, c.; Iu::,uI t, statement
::,LdLt:II lt:I IL as
a::, the
LI 1e buyer
uuy,:,r onlyurrly or UI the
LI ,e seller only. However,
"'"'""'' urrry. nuvv,:,v,:,I , this
LI 11::, form
IUI 111 cannot
l:;dl II IUL be
u,:,
used
u::,,:,u toLU allow
dllUVV an di I individual
II IUIVIUUdl or UI entity
"'' ILILY (such
\ ::,u c;1I as
a::, a
d dealership)
u,:,aI,:,I ::,I llfJ / to "''!:l' I as
LU sign a::, both
UULI I buyer
uuy,:,I and
5:!..!..!.!:! seller
::,,:,11,:,1 for
IUI the
LI'"' purpose
fJUI fJU::,t, of UI disclosing
uI::,c;ll
the odometer reading. This may be accomplished only with the secure power of attorney (HSMV 82995) when:
(a)
(a) the
the title
title is
IS physically
physically being
being held
held by
by the
the lienholder;
henholde,; or
or
(b)
lb_\ the
the title
title is
IS lost.
lost

NOTE:
NOTE: A licensed
licensed dealer
dealer and
and his/her
hrs/her employees
employees are
are considered
considered a
a single
single entity.
entity.

Check your local phone book government pages or visit the following website for current mailing addresses:
http://www.flhsmv.gov/offices/

HSMV 82053 (Rev. 12/11) S www.flhsmv.gov