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UNDER PENALTIES OF PERJURY I/WE DECLARE THAT I/WE HAVE READ THE FOREGOING DOCUMENT AND THAT THE FACTS STATED IN IT ARE TRUE. Dealership Authorized Representative Signature HSMV-MS2001 10/15. FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES DEALER REQUEST FOR REGISTRATION STOP SUBMIT THIS FORM BY FAX 850-617-3946 OR EMAIL UnPaidFeeStop flhsmv.gov Date of Request This Form May Also Be Mailed To / Please Attach 1. Proof of Amount Owed as Shown on Form DHSMV 82041 a Tax Collector Receipt or a Tag Agency Receipt Division of Motorist Services Motor Vehicle Stop Section Neil Kirkman Building 2900 Apalachee Parkway MS 98 Tallahassee Florida 32399 From Dealer / Seller Name Dealer License Number Telephone Number RE Dealer Request for Registration Stop Pursuant to Section 320. Certificate of Registration 2. Cash on Delivery C. O. D. Notice 3. Buyer s Order or Dealer s Invoice 4. 02 16 Florida Statutes Vehicle Year Make Model Vehicle Identification Number License Plate Number Decal Number Owner s Owner Complete Name Owner Driver License Number Co-Owner Complete Name Co-Owner Driver License Number I certify that the amount owed for the title and/or registration fees pertaining to the owner s and the vehicle listed above have not been paid* Amount Owed I also certify that any and all monies and/or trade-in equity received by purchaser was credited ONLY as a Down Payment towards the purchase of the vehicle referenced above. I further certify that No Portion of the Down Payment was applied to the purchase of the title tag or registration of said vehicle. I have also provided documentation clearly indicating the amount owed to the dealership by the purchaser for the applicable title tag and registration fees. 02 16 Florida Statutes Vehicle Year Make Model Vehicle Identification Number License Plate Number Decal Number Owner s Owner Complete Name Owner Driver License Number Co-Owner Complete Name Co-Owner Driver License Number I certify that the amount owed for the title and/or registration fees pertaining to the owner s and the vehicle listed above have not been paid* Amount Owed I also certify that any and all monies and/or trade-in equity received by purchaser was credited ONLY as a Down Payment towards the purchase of the vehicle referenced above. I further certify that No Portion of the Down Payment was applied to the purchase of the title tag or registration of said vehicle. I further certify that No Portion of the Down Payment was applied to the purchase of the title tag or registration of said vehicle. I have also provided documentation clearly indicating the amount owed to the dealership by the purchaser for the applicable title tag and registration fees. 02 16 Florida Statutes Vehicle Year Make Model Vehicle Identification Number License Plate Number Decal Number Owner s Owner Complete Name Owner Driver License Number Co-Owner Complete Name Co-Owner Driver License Number I certify that the amount owed for the title and/or registration fees pertaining to the owner s and the vehicle listed above have not been paid* Amount Owed I also certify that any and all monies and/or trade-in equity received by purchaser was credited ONLY as a Down Payment towards the purchase of the vehicle referenced above. I further certify that No Portion of the Down Payment was applied to the purchase of the title tag or registration of said vehicle. I have also provided documentation clearly indicating the amount owed to the dealership by the purchaser for the applicable title tag and registration fees.