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STATE OF FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES

Division of Motorist Services

NOTICE TO SURRENDER MOTOR VEHICLE/VESSEL

DATE: _____________________

Registered Owner's Name(s): Address: State: City: Zip:

Lienholder's Name: Lienholder's Address: State:

City: Lienholder's Telephone Number:

Zip:

You are hereby given notice to IMMEDIATELY surrender and deliver the motor vehicle or vessel (described below) to the lienholder:

Year: Model:

Make: Body Style:

Vehicle/Hull Identification Number: Color: Registration License Plate Number:

The motor vehicle or vessel shall be surrendered during regular business hours of: ___________________________, between (Days of the Week) the hours of ___________________________ to the following location:

(Business Hours)

Surrender Address for Vehicle or Vessel: State: Zip: Lienholder's Telephone Number:

City:

Failure to surrender the motor vehicle or vessel as required by section 320.1316, Florida Statutes, will result in your name being placed on a list maintained by the Department of Highway Safety and Motor Vehicles, which will prevent you from being issued a license plate revalidation sticker, or replacement license plate for any motor vehicle or vessel under Florida Statute 320.02(17), owned by you at the time this notice was given. If the motor vehicle or vessel is owned jointly by more than one person, the name of each registered owner shall be placed on the list. The stop will remain on all motor vehicles/vessels you own until you have either returned the motor vehicle/vessel or until you pay the full balance owed.

Authorized Signature of the Lienholder:

This form must be accurately completed and signed by the lienholder prior to being sent to the owner. The lienholder should maintain a copy of the completed form for its records. When applying to add a repossession recovery attempt stop, an additional copy of the completed form must be submitted to the department with an accurately completed and signed form HSMV 82191.

www.flhsmv.gov

HSMV 82192 (11/11) S

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