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HomeMy WebLinkAboutVehicle_Car_02/10/2012 A06916 Mail Lien Satisfaction to: Dept of Highway Safety and Motor Vehicles, Neil Kirkman Building, Tallahassee, FL 32399 -0500 I I F Identification Number Year — Make Body — VVT -L -BHP Vessel Regis. No. — Title Number . 2C3CDXAGOCH190540 2012 DODG 4D 4050 108838925 Registered Owner: Date of Issue 05/04/2012 Lien Release VILLAGE OF TEQUESTA Interest in the described vehicle is hereby released 357 TEQUESTA DR ey € TEQUESTA FL 33469 Title Date ► IMPORTANT INFORMATION 1. When ownership of the vehicle described herein is transferred, the seller MUST complete in full the Transfer of Title by Seller section at the bottom of y mail TO: the certificate of title. ► 2 Upon sale of this vehicle, the seller must complete VILLAGE OF TEQUESTA the notice of sale on the reverse side of this form. 357 TEQUESTA DR 3. Remove your license plate from the vehicle. TEQUESTA FL 33469 -3088 4. See the web address below for more information and the appropriate forms required for the purchaser to title and register the vehicle, mobile home orvessel: H http: / /www.hsmv .state.fl.us /html /titlinf.html 3 'a a dt S ✓ Identification Number Year Make Body/ Wr'L BHP Vessel Regis No Tttle dumber Lien Release 2C3CDXAGOGH190540 �2012rDOOG I4D 4050. 11088:38925 Interestin :t+redesGriiedvehlelP.A.. rebyteleasatl Prev Color Primary Brand Seco idary'Brand Braoods Use — Prev Issue Date - By 1 SNte I BLK /WHI POLICE ��' -01 .POLICE.. Title 'e Odometer Status or Vessel Manufacturer or OH use ` ! ull Material —. Arop Date of Issue Date 10 MILES 02/10/2012 ACTUAL I 05/04/2012 Registered Owner 3 ' VILLAGE OF TEQUESTA 357 TEQUESTA DR .* TEQUESTA FL 33469 I st Lieuhalder x - NONE ®' DIVISION OF MOTORIST SERVICES TALLAHASSEE �' . FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES Control Number 1 069028 66 . ® Clayton Boyd VValden Julie L. Jones Director Executive Director TRANSFER OF TITLE BY SELLER (This section must be completed at the time of sale.) Federal author stale lawrcquiee that Iln, seller state the tndege Imo- to ct's narne, sollmp price and d to aold in connection with the iranAer. of omm tip. Failu c to cotnplete or pt'ovitttng a tid a stntement nt ry result in tmas an ihocimprisonmeut. - ¢ " 71tis till. is warranted to he freefiout any liens except as nosed mt the face of the cedifi cafe . and the motor vehicle or vessel:describe[l:is herebytransfetred lo: Seller Most Hader N- 1 . er's Nmne: Adtlt e s: Seller. Mnsl F•.nler Sclhng Ptice ____... ._.. Sellu i4Ltsllnter AalcSol[L __ _, t t L'We stale that this ❑ 5 orF1 6 digit odometer now to tds I_I I_II_I, _I I_II LI X I (no tentho nnlcs,.date read _ and I hereby cedify [hat to the bet of my knowledge the odometer. reading' ❑ 1. reflects ACTUAL MILEAGE, 2. is IN EXCESS OF LCS MECHANICAL LUiITI 3. is NOT THE ACTUAL MILEAGE. UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING DOCUMENT AND THAT THE FACTS STATED 'IN IT ARE TRUE. SELLER Most CO- SELLER Mnsl. Sign Here: _ _ .Sign Hcrc:._ _ ..._: Print Here: Print Here:: r I ' Selling Dealer's LicenseNmnber: . Tax No.' _ "I;,x Collected: S� Auction Natnc •ISicansc Naniliit ... I' PURCHASER Must : CO 1. URC HASF:R M& Si go He _ T _ .!� Stgn'FTct e Prtnl Hcrc T � Pnnt Hem p .- NOTICE., I�ENALTY 15 REQUIRED LAVd.IF NOT SU<;M(TTER FOR TjtANSEE(t y(ITf{IN �6 DpYS (1FTER RATE OF PURCHASE d6. STATE OF FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES DIVISION OF MOTOR VEHICLES 2900 Apalachee Parkway • Neil Kirkman Building - Tallahassee, FL 32399 -0620 Notice of Sale of Motor Vehicle, Mobile Home or Vessel Section 319.22(2), Florida Statutes, requires that the seller file a Notice of Sale with the department within 30 days after the sale or transfer of the motor vehicle, vessel or mobile home. Filing this form removes any civil liability for the operation of the sold motor vehicle, vessel or mobile home. In addition to filing this form, we suggest you keep a copy of your bill of sale (we suggest it be notarized), certificate of title or other type of transaction document showing the vehicle was sold. Complete the information below, tear the top portion of this document at the perforation and mail to the address above or submit to your local tax collector's office or license plate agency. I have this day of transferred by assignment of and delivered Florida Certificate of Title to: Name: Purchasers) Purchaser's DL /ID First MI Last Address Selling Price $ UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING DOCUMENT AND THAT THE FACTS STATED IN IT ARE TRUE. Seller's Signature Co- Seller's Signature NOTE: THE SUBMISSION OF THIS FORM, ACCURATELY COMPLETED, TO A TAX COLLECTOR'S OFFICE, LICENSE PLATE AGENCY OR TO THE ADDRESS ABOVE WILL ALLOW THE TITLE CLERK TO UPDATE THE DMV DATABASE TO REFLECT THE TITLE RECORD AS "SOLD ". HOWEVER, THE OWNERSHIP STATUS WILL NOT CHANGE UNTIL THE PURCHASER APPLIES FOR AND IS ISSUED A CERTIFICATE OF TITLE. i (} DO?) 1F?'f�RC'F.RT(F1C4"ffOJ- ec}cr�l pod statt latvs,iegmra that vou'Siatts tYin;tulcizgew Snni!cc,`uoa Ritll uaiFS�fr ol�oryitar5blp,A�II(rc {O tcNot ?or p(nctdtds'SdaKe Siae3(1Bnt t#yev resi�J {�n fines'audLor tlnprtSpnjjxut SeNlq& DeaiCrs .: Selling Dealers Tat Tae t tcenee. .44— ...._ _. .: .Name._ T ho Collected _ � Shcfng Deate0 Addrhss _ ;Date Sold: _ G Purchasers \grue(s); :: lddress - LAVESTATE THAT THIS 5OR ❑ 6 DIGTT ODOMETER N45S' READS . 7.J..� -.J XX ('dOTL).THS) MILES. IIATE:READ - -: /_ / ,AND 1 HEREBY na C.ER'i1FY THAT �O THE BEST OF MY KNOWLEDGE THE ODOMETER READING: c, y CAUTION: READ CAREFULLY I. REFLECTSACTUAL MILEAGE 2. IS IN EXCESS OF ITS MEC -:4-I s•IITS ❑ 3 IS:N0.T THE ACTUAL MILEAGE. F BEFORE YOU i,EXC .OF ITS MECHANICAL LIMITS WARNING ODOMETER DISCREPANCY CHECK A BOX APPLIES TO 5 DIGITODOMETERS) .z Purchaser Must Co- Purclu ser4Must L Sign Here: Sign Here: - - _ _ B Print Hcre: __ Print Here: a --Agent Must Auction Name (When Applicable): _ Sign Here: Print Hem: __ Auction License Number: Selling Dealer's Selling Dealer's Tax Tax License No.; Name: - _ No.: _- Collected: m Selling Dealer's Address: - _ _ _____ - Date Sold: .J _O Purchaser's Name(s): Address: m : 1 /WE STATE THAT THIS ❑ 5 OR ❑ 6 DIGIT ODOMETER NOW READS CT1 XX (NO TENTHS) MILES, DATE READ /_ i , AND I HEREBY u CERTIFY THAT TO THE BEST OF MY KNOWLEDGE THE ODOMETER READING: M - CAUTION: RE - AD CAREFULLY E-1 1. REFLECTSACTUAL MILEAGE 2, IS IN EXCESS OF ITS MECHANICAL LIMITS ❑ 3 - . IS NOT THE ACTUAL MILEAGE. Z : BEFORE YOU (EXCESS .OFITS MECHANICAL LIMITS _ WARNING. - ODOMETER DISCREPANCY tz CHECK A BOX - APPLIES TO 5 =DIGIT ODOMETERS) R . Purchaser Must Co- Purchaser Must - Sign Here: _ _ Sign l -lere: - rc Ad Print Here: _ Print Hu c: z Q -w Seller /Agent Must Auction Name (R hen Applicable): Sign Here: —_ —_ . -- Print Here: _ Auction License Number: Selling Dealer's Selling Dealer's Tax "fax License No.; Name: __ __ _ No.: Collected: Sold: Date o: w Selling Dealer's Address: Da -- _. _ — - :� Purchaser's Nanre(s): - _ Address: C = W _ I/WE: STATE 'THAT THIS F1 5 OR ❑ 6 DIGIT ODOMETER NOW READS XX (NO TENTHS) SALES. DATE - RE 4D- '_ '. , AND THEREBY CERTIPY THAT TO THE BEST OF MY KNO« "LEDGE THE ODOMETER READING: m CAUTION: READ CAREFULLY � 1. REFLECTS, ACTUAL MILEAGE ❑ 2 IS N EXCESS OF ITS NtECHANtCALLIMITS _- � 3. IS NOT THE ACTUAL MILEAGE. BEFORE YOU (EXCESS OFITS MECHANICALI 1MITS WARNING -- ODOMETER DISCREPANCY z :CHECKABOX - APPLIES:T05 DIG ITDDOMETERS).. j Purchaser Must ..Co Purchask Moil' n Herc, .v Sign crc; _. -... : :; -:— :. :.. Sig -- _ Tom , -� �. -- -- .. W . Pent Here, f rr Selte6l4ept Must Auctton Satr r (when 4p¢]rrablel _ _ - $igp,Hcre _ �a Pnq tteM __ 'A c't�gn Lreetise Xwmbgr . .S:ii. irN':: ..y.:[•:v0 ?: —. :'.tt . r :. _.....:. �_ - `::� .r - cw _.wrJrnn. - fN- ...,"[ .ant•. %....t , ... , li......, : _. - -. n Iflr .., .. tr, td': ifs .: -.- .. , u t lCtu t•�' -- fl rErrc .•. ; y % t; i`:'r1',t,. tjd r. ;r%Ci• r��; 1j il y F 4.d.•' •. It.. i ":. fY - .: ; rr t til a it 1 �EIY SJ ii V ' • 4... I' A ,.. SS•: i ' :'� ' - �J . ' 'I'rrt•: 5 • • 1 • 1 s ^�.t4 ltsr;�i .s• C'il�:sr ry _ ,.. , Y.atr, ..� �t'^'lrf� f�''€.: �• 11 r � r �.I1 r. .'� : ::'� A .-� tea. /1 �o-d /► 1¢y r� { � r ^'SCtili�:�j r.., t, ��b r ).^ : ., ,� '�jli� �• %1 ,(1 3 ' �S� ° h� , - 's - f �8 ° � nt:.. CH f2YSLER Chrysler Group LLC ^t ' 3` 4 ' DATE INVOICE NO.,• ` 12 -23 -11 CLDD26090779 �f_ VEHICLE IDENTIFICAIION NO. YEAR MAKE i s. I 2C3CDXAGOCH190540 2012 DODGE { y i ' t BODY TYPE SHIPPING WEIGHT 3/�dzyj SfYf% g FOUR DOOR SEDAN 4050 F H.P. (S.A.E.) G.V.W.R. NO. CYL.S, SERIES OR MODEL fin 34.3 6 CHARGER POLICE RWD "i`•! : ` =Y IIII III IIIIIIiI Illlllllllllilllllilllll IIII �I'I! II I III !�: !!1111 II I, the undersigned authorized :representative of the company, firm or corporation named below, hereby cer-t g p P Y tify that the new vehicle described above is the property of the said company, firm or corporation and is transferred on the above date and under the Invoice Number indicated to the following distributor or dealer. NAME OF DISTRIBUTOR, DEALER, ETC. DEALER NUMBER 44940/44940 I? r• '` MAROONS DODGE OF PEMBROKE PINES f''i °I A. N U ff :i 13601 PINES BLVD i1? ai PEMBROKE PINES FL 33027 i; 'ya fEE� Ip► ° . i e' It is further certified that this was the first transfer of such new vehicle in ordinary trade and commerce. MAIL TO: MAROONS DODGE OF PEMBROKE PINES CHRYSLER ROUP LLC 13601 PINES BLVD -- - - - - -" PEMBROKE PINES FL 33027 �n r W 'v: ►: o ..;,.�� (SIGNATURE OF AUTHORIZED REPRESENTATIVE) (AGENT) c :. 06058161 AUBURN HILLS MICHIGAN !'�•''� CITY - STATE "CERTIFIED FOR SALE IN ALL 50 STATES" Ijl` t/ 'tYi a II + 7tr i !p� y; /et aid, 1 ,�:; /eA s it, 1 t . i t ������� er Each undersigned seller certifies to the best of his knowledge, information and belief under penalty of law that the vehicle is new and has not been registered in this or any state at the time of delivery and the vehicle is not subject to any security interests other than those disclosed herein and warrant title to the vehicle. i FOR VALUE RECEIVED I TRANS R THr vFHiCi F QF1QRlBED N THE FACE OF THIS CERTIFICAT NAME OF PURCHAS ) w w w be ADDRES m D I certify to the bes of m knowledge that m adings No Tenths z F- Z RS Y DEALS NAM F DEALEHIP DEA LICENSE NUMBER :D w Bein ly sworn upon oath says hat Inr state co Z forth true a d I. Subsc d m to m Fr State of before 1 day of 20U o to County of Notary Publ USE NOTARIZATION ONLY IF REQUI TITLING JURISDICTION NAME OF IONG- cc PURCHASER(S) w egM . �u \�C• I ¢ ADDRESS ,,run,,, e: \ 9N 0 D Z I certify to the best of my knowledge that the odometer reading is •` enibs ; :.:• a th p Z BY DEALER NAME OF DEALERSHIP DEALER'S LICENSE NUMBER CD LU Being duly sworn upon oat ate set i to me ¢ (5 before of before this day of 20—. O County of Notary Public Q USE NOTARIZATION ONLY IF REQUIRED IN TITLING JURISDICTION NAME OF PURCHASER(S) w Cl w ¢ Co ADDRESS t o D I certify to the best of my knowledge that the odometer reading is IN Tenths Z p H DEALER BY Z NAME OF DEALERSHIP DEALER'S LICENSE NUMBER m W Being duly sworn upon oath says that the statements set Z forth are true and correct. Subscribed and sworn to me H z State of before this day of 20— m rn County of E3 U) Notary Public 4 USE NOTARIZATION ONLY IF REQUIRED IN TITLING JURISDICTION NAME OF Cc PURCHASER(S) "' w t ¢ co ADDRESS 0 D I certify to the best of my knowledge thai the odometer reading is No Tenths z O Z BY DEALER NAME OF DEALERSHIP DEALER'S LICENSE NUMBER m UJ Being duly sworn upon oath says that the statements set z forth are true and correct. Subscribed and sworn to me Fr State of 0 before this By of 20— o U) C ounty of Notary Public T ITLING 'QIAR17ATION ONLY IF REQUIRED IN Federal law recutres you fo state the oc! mele- in connection with the transfer o ownership. Failure to complete or provide a false statement may result in fir -: I certify tc - — reading is the actual mileage of t ehicle unless one of the following statements is checked. Odometer .7, Reading (C�,r _ - ileage stated is in excess of s echanical limits ❑The odometer reading is not the actual mileage. J W RNIN DOMETER D SC EPpyC Signaturets - 1 o2-c�7 U l,UR7�te S Cement I s Sale U) d Printed Names) of Seuegsl alers No. g ly wom upon oath says that the atements set 0 1 forth a t and correct. Subsc' nd m to me F­ Signature of Purchaser(s) w ¢ bef re is t By 0f 20 W Printed Name of Purchaser(s) Notary Public p Company Name (if Applicable) State f Address of Purchaser(s) ty ,��'� \��. w • .�s /, USE NOTARIZATION ONLY IF RE ED I TITLING JURISDICTION 1st lien in favor of whose address is J i v'v Oz 2nd lien in favor o -¢' W whose address is r ` " J STATE OF FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES DIVISION OF MOTORIST SERVICES SUBMIT THIS FORM TO YOUR LOCAL TAX COLLECTOR OFFICE www.fihsmv.aov/offlces APPLICATION FOR CERTIFICATE OF TITLE g V ; 1lI B TH/WTH OUT REGISTRATION I ECK APPLICATION TYPE I ORIGINAL TRANSFER VEHICLE TYPE MOTOR VEHICLE l.. J MOBILE HOME VESSEL OFF - HIGHWAY VEHICLE i ' ATV ri ROV MC 1 OWNER / APPLICANT INFORMATION Customer Number Do you want the certificate of title to Owner Co -Owner Unit Number Fleet Number remain electronic ? Are you a Florida resident? e ° yes j no �� {yes no eyes nno Are you an alien? 3 yes I no ;yes f7no - , OR f h - , AND NOTE: When joint ownership, please indicate if "or' or "and" is to be shown on title when issued. If neither box is checked, the title will be issued with "and." If applicable: F Life Estate /Remainder Person r Tenancy By the Entirety With Rights of Survivorship l Owners County of Residence: E Name r' As It App ars on Driver Licens (First, Full Middle/Maiden, & Last Name) Owner's Email Address Date of Birth Sex FL Driver License or FEID /Suffix # Co-Own ssee's Name As It Appears on Driver License (First, Full Middle /Maiden, & Last Name) Co- Owner's /Lessee's Email Address Date of Birth Sex FL Driver License or FEID /Suffix # Owner's Mailing Address(Mandatory) City Zip Q !f ueS�- L 33Z4 CO Co- Owner's /Lessee's Ma ding Address (Mandatory) City State Zip Owner's/Lessee's Physical Street Address in Florida (Mandatory) Cit State Zip Mobile Home Physical Address (if applicable) Check B In a mobile home rental park with 10 or more lots. n City State Zip Mail To Customer Name (H different From Above Owner) Mail To Customer's Email Address I Date of Birth Sex FL Driver License or FEID /Suffix # Mail To Customer Address (If different From Above Mailing Address) City State Zip 2 MOTOR VEHICLE MOBILE HOME OR VESSEL DESCRIPTION Vehicle/Vessel Identification Number t,- Make/Manufacturer Year 9 d � Color Florida Title Number rT Previous State of Issue I License Plate or Vessel Registration Number Weight Length BHP /CC GVW /LOC VAN USE, IF APPLICABLE Ft. In. PASSENGER 13 OTHER TYPE HULL MATERIAL PROPULSION FUEL *DRAFT OF VESSEL Open Motorboat rl Houseboat ri Personal Watercraft Wood Aluminum 0 Outboard Sail rJ Gas The depth of water Cabin Motorboat 173 Pontoon rl canoe Fiberglass Steel 0 Inboard Air Propelled Diesel vessel draws) Auxiliary Sailboat 0 Airboat Other ( Wood/Fiberglass 0 Inboard /Outboard Electric Inflatable 11 Sailboat Specify Other Other J Other FT. IN, * For all vessels 26' or more in specify Specify Specify lenat and alf sailboats USE OF VESSEL PREVIOUS Recreational (Pleasure) Commercial Blue Crab 1 Commercial Stone Crab Government 0 Commercial Sponge OUT -OF -STATE Dealer/Manuf. a ` Commercial Fish Commercial Live Bait 3 Commercial Shrimp Recip. 0 Commercial Charter 0 Commercial Other REGISTRATION NUMBER: Exempt t Hire (Livery) Commercial Mackerel Commercial Shrimp Non -Recip rl Commercial Oyster Commercial Spiney Lobster Previously Federally Documented Vessel, Attach Copy of: State of Principal Use 1 U.S. Coast Guard Release From Documentation Form; or L Copy of Canceled Documentation Papers BRANDS USAGE AND TYPE Check Applicable Boxes SHORT TERM LEASE 'LONG TERM LEASE r1REBUILT OPOLICE VEHICLE 171 PRIVATE USE 'TAXICAB OFLOOD VEHICLE ILEV VEHICLE ASSEMBLED FROM PARTS REPLICA KIT CAR OGUDER KIT r MANUFACTURER'S BUY BACK r,' ELECTRIC VEHICLE LIENHOLDER INFORMATION CHECK - f FEID # -PL At and Sex and Dale ofpirth DMV Account # Date of Lien Lienholder's Name CELT USTOMER © � / C ELT Lienholders Email Address Lienholder's Address City State Zip If Lienholder authorizes the Department to send the motor vehicle or mobile home tite to the owner, check box and countersign: (Does not apply to vessels). If box is not check title will be mailed to the first lienholder. (Signature of Lienholder's Representative) TRANSFER TYPE IF WNERSHIP HAS TRANSFERRED, HOW AND WHEN WAS THE VEHICLE, MOBILE HOME, OR VESSEL ACQUIRED? %/'� f SALE p-;- :;GIFT _ REPOSSESSION COURT ORDER OTHER (SPECIFY) DATE ACQUIRED l w I ODOMETER DECLARATION WARNING: Federal and State law reouires that you state the mileage in connection with an application for a Certificate of Title Failure to complete or providing a false statement may result in fines or imprisonment IANE STATE THAT THIS J 5 OR f. - 16 DIGIT ODOMETER NOW READS ®� f AX (NO TENTHS) MILES, DATE READO / ll v/ /G— AND I/WE HEREBY CERTIFY THAT TO THE BEST OF MY /OUR KNOWLEDGE THE ODOMETER READING: 1, REFLECTS ACTUAL MILEAGE. _ 2. IS IN EXCESS OF ITS MECHANICAL LIMITS. 3. IS NOT THE UAL MILEAGE. DEALER SALES TAX REPORT AND VEHICLE TRADE IN INFORMATION IF APPLICABLE ruORIDA SALES TAX R RATION NUMB DATE OF SALE q DV `NSE OUNT OF TAX DEALE URE DL D YEAR OF TRADE IN MAKE OF TRADE IN TITLE NUMBER OF TRADE IN (IF KNOWN) VEHICLE IDENTIFICATION NUMBER 0 ADE IN HSMV 82040 (REV 06111) S www.flhsmv.gov MOTOR VEHICLE IDENTIFICATION NUMBER VERIFICATION THIS SECTION REQUIRES A PHYSICAL INSPECTION AND A VERIFICATION OF THE VEHICLE IDENTIFICATION NUMBER IN (OR THE MOTOR NUMBER FOR MOTOR VEHICLES MANUFACTURED PRIOR TO 1955) OF THE MOTOR VEHICLE DESCRIBED ON THIS FORM BY A LICENSED DEALER, FLORIDA NOTARY PUBLIC, POLICE OFFICER, OR FLORIDA DIVISION OF MOTOR VEHICLES EMPLOYEE OR TAX COLLECTOR EMPLOYEE. IF THE VIN IS VERIFIED BY AN OUT OF STATE MOTOR VEHICLE DEALER, THE VERIFICATION MUST BE SUBMITTED ON THEIR LETTERHEAD STATIONERY. COMPLETE THIS SECTION ON ALL USED MOTOR VEHICLES, INCLUDING TRAILERS, (WITH ABBREVIATION OF "TL" WITH A WEIGHT OF 2,000 POUNDS OR MORE) NOT CURRENTLY TITLED IN FLORIDA. I, the undersigned, certify that I have physically inspected the above described vehicle and find the vehicle identification number to be: (Vehicle Identification Number) DATE SIGNATURE PRINTED NAME Law Enforcement Officer or Florida Dealer /Agency Name Badge # or Florida Dealer # Notary Stamp or Seal FL DMV/Tax Collector Employee Florida Compliance Examiner/Inspector Badge or ID Number COMMISSIONED NAME OF FLORIDA NOTARY: NOTARY'S SIGNATURE (Print, Type or Stamp) SALES TAX EXEMPTION CERTIFICATION THE PURCHASE OF A RECREATIONAL VEHICLE TO BE OFFERED FOR RENT AS UVING ACCOMMODATIONS DOES NOT QUALIFY FOR EXEMPTION. I CERTIFY THE RECREATIONAL VEHICLE, MOBILE HOME OR VESSEL DESCRIBED HAS BEEN PURCHASED AND IS EXEMPT FROM THE SALES TAX IMPOSED BY CHAPTER 212, FLORIDA STATUTES, BY: rJ PURCHASER (STATE AGENCIES, COUNTIES, ETC.) HOLDS VALID EXEMPTION CERTIFICATE CONSUMER'S CERTIFICATE OF EXEMPTION NUMBER r] MOTOR VEHICLE , MOBILE HOME � VESSEL WILL BE USED EXCLUSIVELY FOR RENTAL SALES TAX REGISTRATION NUMBER I hereby certify that ownership of the motor vehicle, mobile home or vessel described on this application, is not subject to Florida Sales and Use Tax for the following reason: INHERITANCE GIFT DIVORCE DECREE 0 TRANSFER BETWEEN HUSBAND AND WIFE r3 EVEN TRADE OR TRADE DOWN (State the facts of the even trade or trade down and the transferor information, including the transferor's name and address, below under "Other: Explain. ") OTHER (EXPLAIN) 10 1 REPOSSESSION DECLARATION IF CHECKED, THE FOLLOWING CERTIFICATIONS ARE MADE BY THE APPLICANT: I CERTIFY THAT THIS MOTOR VEHICLE, MOBILE HOME OR VESSEL WAS REPOSSESSED UPON DEFAULT IN THE TERMS OF THE LIEN INSTRUMENT AND IS NOW IN MY POSSESSION. (VESSEL) A PHOTOCOPY OF THE LIEN INSTRUMENT FOR THE VESSEL IS REQUIRED AND ATTACHED. 01 1 AM REQUESTING THAT AN ORIGINAL CERTIFICATE OF REPOSSESSION BE ISSUED FOR THE MOTOR VEHICLE OR MOBILE HOME IN LIEU OF A TITLE (REPOSSESSION). 1 AM REQUESTING THAT A DUPLICATE CERTIFICATE OF REPOSSESSION BE ISSUED FOR THE MOTOR VEHICLE OR MOBILE HOME, AS THE ORIGINAL HAS BEEN LOST OR DESTROYED. 11 NON -USE AND OTHER CERTIFICATIONS IF CHECKED, THE FOLLOWING CERTIFICATIONS ARE MADE BY THE APPLICANT: r 7 1 CERTIFY THAT THE CERTIFICATE OF TITLE IS LOST OR DESTROYED. THE VEHICLE IDENTIFIED WILL NOT BE OPERATED ON THE STREETS AND HIGHWAYS OF THIS STATE UNTIL PROPERLY REGISTERED. THE VESSEL IDENTIFIED WILL NOT BE OPERATED ON THE WATERS OF THIS STATE UNTIL PROPERLY REGISTERED. OTHER: (EXPLAIN) APPLICATION ATTESTMENT AND SIGNATURES IANE PHYSICALLY INSPECTED THE ODOMETER/VIN AND FURTHER AGREE TO DEFEND THE TITLE AGAINST ALL CLAIMS. (More than one form HSMV 82040 may be used for additional signatures.) UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING DOCUMENT AND THAT THE FACTS STATED IN IT ARE TRUE. SIGNATURE OF APPLICANT (OWNER) Date SIGNATURE OF APPLICANT (CO-OWNER) Date 13 1 RELEASE OF SPOUSE OR HEIRS INTEREST The undersigned person(s) state(s) as follows: That died on (Name of Deceased) (Date) testate (with a will) intestate (without a will) and left the surviving heir(s) named below. When applicable, the heir(s) (named below) certifies that the certificate of fide is lost or destroyed. UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING DOCUMENT AND THAT THE FACTS STATED IN IT ARE TRUE. (More than one form HSMV 62040 may be used for additional sianatures ) Print or Type Name of Spouse, Co -owner or Heir(s) Signature of Spouse, Co-Owner or Heir(s) That at the time of death the decedent was owner of the motor vehicle, mobile home or vessel described in section 2 of this form. The person(s) signing above hereby releases all of his/her/their right, title, interest and claim as heir(s) at law, legatee(s), devisee(s), or otherwise to the aforesaid motor vehicle, mobile home or vessel to: Name of Applicant(s) (Print or Type) RESIDENTS OF FLORIDA AND ALL VESSEL OWNERS, RESIDING IN FLORIDA OR OUT OF STATE, SHOULD SUBMIT THIS FORM AND ALL REQUIRED DOCUMENTATION TO A LOCAL FLORIDA TAX COLLECTOR'S OFFICE OR THE FLORIDA TAX COLLECTOR'S OFFICE LOCATED IN THE APPLICANTS COUNTY OF RESIDENCE FOR PROCESSING. Check your local phone book government pages or visit the following webelte for current mailing addresses: hftp: /Avww.flhsmv.aov /offices/ HSMV 82040 (REV. 06111) S www.flhsmv.gov Maroond Dodge of Pembroke Pines 13601 Pines Blvd M a roone 6309 940 78609 CH1 O51 Pembroke Pines, FL 33027 0 954 - 441 -2000 SOLD TO r DATE INVOICE NUMBER STOCK NUMBER VILLAGE OF TEQUESTA ADDRESS 0211012012 0 015 8 5 l: H i y05 40 345 TEQUESTA DR DESCRIPTION ACCT. NO. CITY TEQUESTA FL. 33469 STATE ZIP SALE PRICE 2726 P TELEPHONE TAX# R TRADE YEAR MAKE MODEL COLOR I El C' DODGE CHARGER PITCH BI X ; EXTENDED WARRANTY C VIN 2C3CDXAGOCH19(. E TIRE BATTERY FEE FLEET MANAGER FED. ID # C �lu('!1 i_. 0 9. O FLEET # P.O. # 78609 F oTHFR FFFC If :I OPTIONAL EQUIPMENT AND ACCESS DESCRIPTION PRICE v E TOTAL WE OWEI H I C L CAR DEAL NUMBER E SALES TAX 324 LICENSE a TITLE 311T TOTAL PRICE DUE DESCRIPTI OF YEAR MAKE MODEL COLOR MILES ACV VALUE TRADE \I j ii OF STOCK TRADE NUMBER VIN Chrysler Group LLC CHRYSLER GROUP SERVICE CONTRACT APPLICATION VEHICLE AND PURCHASER INF ORMATIO N VEHICLE ID NUMBER YEAR /MAKE /MODEL ODOMETER AND TYPE MILES KM I IN- SERVICE DATE PRIMARY PURCHASER'S FIRST & LAST NAME OR COMPANY NAME OPTION SALE DATE ❑ MR ❑ MRS ❑ MS ❑ OTHER niq SECONDARY PURCHASER FIRST & LAST NAME PRIMARY PURCHASER'S EMAIL ADDRESS ❑ MR ❑ MRS ❑ MS ❑ OTHER PRIMARY PURCHASER'S ADDRE S \ STATE ZIP HHONEW NUMBER El El El PHONE NUMBER H W C C OVERAGE INFORMATIO PROGRAM NAME / TERM OPTION CODE / CUSTOMER SALES TOTAL N/C PAYMENT AMOUNT AMOUNT DEDUCTIBLE PAID AMOUNT TAX FLAG METHOD DOWN FINANCED 0 1_ CT411LE DEDLICTIBLE DEDUCTI DEDUCTIBLE TOTALS CHECK BOX NO CHARGE METHOD KEY PAYMENT METHOD KEY: EMPLOYEE PURCHASE ❑ YES ❑ NO IF TAX EXEMPT DI - DEALER INCENTIVE C. CASH B. FINANCED W/ VEHICLE ❑ P - PART OF PACKAGE A. DLR PAYMENT PLAN R. RAPID REMIT THE TIME AND MILEAGE LIMITS OF ALL NEW VEHICLE PLANS BEGIN FINANCE SOURCE (COMPLETE ONLY IF FINANCED WITH VEHICLE) THE DATE THE VEHICLE WAS FIRST PUT IN SERVICE AT "0" MILES IMPORTANT NOTICE TO PURCHASER..... . Your signature means the plan and the actual service contract indicated above has been reviewed by {you and, if your application is approved by Chrysler Group Service Contracts, you accept its terms and conditions. This service contract is not required to purchase or finance a motor vehicle. Consumers in the State of Florida: The rate charged for this agreement is not subject to regulation b he Florida Office of Insurance Regulation. *NOTE: WHEN THERE IS AN EXISTING WARRANTY ON A VEHICLE, THE CONTRACT TERM WILL INCL bE THE WARRANTY PERIOD. REFER TO YOUR CONTRACT PROVISIONS FOR A DEFINITION OF "IN- SERVICE" DATE. PURCHASER'S DATE I I SIGNATURE X DE ALER • - • D QLER HIP NAME (� TELrIO,IG O STREFpD RES �J C TY TATE & ZO D DE IMPORTANT NOTICE TO DEALER..... . Your signature on this form signifies that: (1) This vehicle qualifies for the service contract; (2) You have reviewed the s ce contract with the purchaser; (3) You have delivered a copy of this form to the purchaser for the amount you have recorded on the form; (4) You will provide service to the purcha in accordance with the provisions of the service contract Chrysler Group will issue to the purchaser; (5) You have treviewed the Chrysler Group Service Contracts Dealer Guide a agree to abide by the policies and procedures specified ITla therein. (6) Chrysler Group y -set off money it MurnbVirs9for any claim due to a breach of representati � _ AUTHORIZED .. SALESPERSON NAME t' DEALER SIGNATURE X DATE IMPORTANT! The following vehicles are not eligible for a Chrysler Group Service Contract: Vehicles equipped for right -hand drive; Motor o es; Vehicles placed in taxi or limousine service (except vehicles placed in van pool service); Vehicles used for emergency service, ambulance service; Vehicles used for postal service or severe off -road u Vehicles altered or converted from the original manufacturer's specifications; Vehicles converted from two -to four -wheel drive; Vehicles equipped with a Diesel engine (except Chrysler Group, Ford and GM vehicles); Vehicles that operate on other than Gasoline or Diesel Fuel Systems (e.g., natural gas, electric and hybrid) except Chrysler Group vehicles; Vehicles with a gross vehicle weight rating (GVWR) of over 14,000 pounds (Except Dodge Medium Duty Commercial Trucks); Vehicles not used in accordance with manufacturer's specifications for payload and /or towing capacity; Any vehicle where the factory warranty has been voided or restricted by the manufacturer; Vehicles registered outside of the United States, Guam and Puerto Rico; Any vehicle that is declared to be a total loss by any insurance company, is rebuilt after being declared to be a total loss, or is issued a certificate of title indicating that it is designated as "salvage," "junk," "rebuilt" or words of similar impact. N indicated above. • • • YOUR PLAN PROVISIONS • DAYS, • NE THE TOLL FREE NUMBER LISTED BELOW. you of acceptance by mailing your Plan Provisions. IF This document is an application for the Chrysler Group Service Contract and does not constitute a service contract until accepted by Chrysler Group Service Contracts. TOLL -FREE TELEPHONE ASSISTANCE IS AVAILABLE 8:30 A.M. THRU NOON OR 1:00 P.M. THRU 5:00 P.M. EASTERN TIME MONDAY THRU FRIDAY. CA. LIC # OG94472 FL. LIC # 65505 1- 800 - 521 -9922 www.servicecontracts.chrysier.com Rep. 20110628 (81- 770- 3012FL) (Rev. 7/11) COPIES: #1 (BLACK) DEALERCONNECT ENTRY DOCUMENT #2 (GREEN) FINANCE SOURCE (IF ANY) } } ? f S > #3,(BROWN)TOOWNER" !! f ISIS ! $ ! ! 1 !! ! f S ! ! > + f ! S f t S s + #4 BLUE DEALER'S FILE t f ! ! S ! ! S f ! 1 f t f 1 f ! ! ? 4 S f S S } > ! S ! S T S ? ! T S + S ! ! f ! 4 ! ! ! ! ! ! ! ! f ! ! 1 f 1 ! ! f ! S } } ? ! ! ? ! ! ! ! ! ! 4 4 ! ( BLUE) . • a a a 4 4 ++ a a 1 .+ a+ 4 a a 4 1 a a♦ v • a+ a• a a a . .• a...• a a*+ a+ a