Form Hsmv 84061 S - Declaration Affidavit For A Motor Vehicle Which Will Be Titled And Registered In Another State Or Country

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STATE OF FLORIDA
DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES
DECLARATION AFFIDAVIT FOR A MOTOR VEHICLE
WHICH WILL BE TITLED AND REGISTERED IN
ANOTHER STATE OR COUNTRY
Date Purchaser(s) Signed:___________________
I/we, do hereby attest, pursuant to section 319.23(6)(a), Florida Statutes, that I/we
purchased a motor vehicle described as a: _______________, ________________,
(Year)
(Make)
________________________________________, on _________________, from
Vehicle Identification Number (VIN)
(Date)
_______________________________________, and further declare that I/we will be
(Complete Name of Selling Dealer)
responsible for applying for title and registering the vehicle in another state or country.
Under penalties of perjury, I declare that I have read the foregoing document and that the
facts stated in it are true.
____________________________________
____________________________________
Purchaser’s Printed Name
Purchaser’s Signature
______________________________________________________________________________
Purchaser’s Complete Address
____________________________________
____________________________________
Co- Purchaser’s Printed Name (when applicable)
Co-Purchaser’s Signature (when applicable)
______________________________________________________________________________
Co-Purchaser’s Complete Address (when applicable)
HSMV 84061 S (08/11)

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