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Affidavit Establishing Exemption Under Florida Statutes 316.0083(1)(D) Form - Orange County Public Works Department Page 3



Copy of a police report showing the deceased owner’s registered license plate or motor vehicle was

stolen after the owner’s death but on or before the date of the alleged violation.

I have provided ______________________________ to satisfy the requirements of this section.

3. I understand that Florida Statutes § 316.0083 requires that I provide detailed information supporting

the exemption(s) I have identified in Paragraph 2, which may include the facts and circumstances

supporting the exemption I have asserted. That detailed information is as follows (attach additional

sheets as necessary):

__________________________________________________________________________________________

4. The foregoing statements are true and correct.

_____________________________________________

Signature of Registered Owner

_____________________________________________

Phone Number

_____________________________________________

Email of Registered Owner

VERIFICATION OF NOTARY OR PERSON AUTHORIZED TO ADMINISTER OATHS

STATE OF ____________________

)

COUNTY OF_______________ ___

)

Sworn to and subscribed before me on _________

, 20__, by ________________________, who is ____

personally known to me or ____ provided identification, and who did take an oath.

__________________

Notary Public, State of Florida

Printed Name:___

My Commission Expires:___________________

MAIL TO:

Orange County Public Works Department

4200 South John Young Parkway

Orlando, FL, 32839

Affidavit Establishing Exemption Under Florida Statutes 316.0083(1)(D) Form - Orange County Public Works Department Page 3