HomeMy WebLinkAboutFlorida Department of Highway Safety and Motor Vehicles Affidavit to Accompany 1982 06 30
..
P 2-dd4L- (./3 ,:'J i-~ ~ iJEi' / :/. "
' . -t:~~- "', .;" /ft/' :i,f.l/~ ;.~ ~.
.' . " ~~~4
^ /.7~.f{,B4~(l;lEU\V)l[~~
b~~~ '"t- t,jJ.::;a;. t:J ';)
'.. <.-
'-r.,.-;~ 3:A3dy'
f iU'-r./
21690251 CORRECTION SHEET JUN 214~m'@
130 (J;'I of WINTER SPRINGS
CITY HAlt
.. OHSMY.Y.0l5 (10/81)
I ~4
Title No.
City of Winter Springs
400 N Edgemon Aw"
Winter Sprmg flY. 31708
D.H.S.M.V. Office Agency
Attention: Billy King
COUNTY #68
REPORT #226
AGENCY #1
Make and 1.0. No.
'82 Whit
XDCHUFlCN052049
Ex.
2.00
BBW/vw
For Applicant
Date
same
Cr. Held $
6/21/82
We are returning all documents submitted.
The vehicle Identification NUmber must be physically examined and Fonn
42.3 completed by the Applicant. We also need either a sworn affidavit
from the seller and purchaser verifying that the vehicle Identification
Number shown on the affidavit is identical to the vehicle Identification
NUmber shown on the MOtor Vehicle OR need the Identification.NUmber
verified on Fonn 42.3 byFla MOtorlVehicle Dealer, Fla. DMV Inspector,
Police Off,icer of Fla. Notary Public.
No alteration on Fonn 42.3 is acceptable.
. ~
Submit a notarized, affidavit that Winter Spring Fire Department and City
of Winter Springs ,are one and the same.
IMPORTANT: THIS FORM AND ANY ENCLOSURES WITH THE ABOVE OBJECTIONS REMOVED OR
CORRECTED, MUST BE RETURNED TO AVOID FURTHER DELAY IN THE ISSUANCE OF
A FLORIDA TITLE.
.
.
0'
DHSMV-V 42.3 (REV. 10/81) S:r ATE OF FLORIDA
DEPARTMENT OF HIGHWA Y SAFETY AND MOTOR VEHICLES
Division of Motor Vehicles
NEIL KIRKMAN BLDG. TALLAHASSEE 32301
SECTION 319.23 F.S.
AFFIDAVIT TO ACCOMPANY APPLICATION FOR
ORIGINAL FLORIDA TITLE CERTIFICATE UPON MOTOR VEHICLES,
NEW OR USED, PREVIOUSLY REGISTERED OR PURCHASED
IN A FOREIGN STATE
NOTE: Usc the cngirn.- number as the identification number for car)and trucks made
heron: 1955. For f9,SS & lalcr models. use (he vehicle idenlific.:Uion (serial) numher.
the state of Vir
\>lllll'"r."
a~d/se~'i~1 nllmbers find sa
,.," \ \ I I,. J ~ ()<" '0,.
. . , \
This is to certify that I, the undersigned, am the owner(s) of the fOllowing described motor vehicle:
ye~r 1982 ,make White , type Fire Truck, previously registered or purchased in
c rtify that upon actual physical examination of the engine
DATE
6/30/82
. ,\ ,
,.'\ \ i , , "S:igf(~d.,' ".
j "" 'I ) ,\ ': ~ wner(s s gnatur
' ,'1.<)'11,. I /J. ~
\ ." ;) Ii:\ I. \s\l~'~fi~d and Swnrn to before me at ,;)1-/~. ~ in the
....JEjLJ..""Si~i~:;,i ,1'" ./~ . This SOU day of IL: . 19 .f'.:/,
'..., ,\, \, ,/ - ""'. ,-;r-., ~ry Pubk State of Florida at L
Notar,i'Publ;c .h1... "'-'l- .(. . /7 <:H..e;...,) Date Cumml"io"~,... [ . Ap, I .".
~onc!~<I 61. ~~g F~'~~ual~ ~m 7983
VIN MUST ALSO BE VERIFIED BY ONE OF THE FOLLO WING __," ~ pell)!
TlFICA TION NUM8ER/.wX \)C/}/ /..llc/ c'/Vo -S-2.D~
t t
Florida Motor Vehicle Dealer
(Exception: any trailer-type recreational vehicle or any mobile home)
DMV Inspector
Name
Name
Dealer license #
Badge #
Signature
Police Officer. Any Jurisdiction in any State
Badge # 7 /-0
Signature ,\' ii' ,
FI "d N t /~":~I\ Nlltal'!{"pobJic,' State of Florida at large
orl a 0 ary'. U\lI(' "" ,,'" '0 . .
.' '~ .,' My COJnIlllSSIO/J Exptres Aprrl 4. 1983
:' , ) " '. ,'Ilot.c!ed 8y American F;l8 & C.suolly Com".ny
Date COlT!mission;Expir;es' , ,
I : ....:. I ,_ I ..q~' ~
Signature~:7, :1 >! n;~~~
Seal ",/,1.'
'. . " \ .
'>" I
>.,
I
,
Jurisdiction 1.>>~
4u?
Signature . .
, '
I I (
l j ,; \
CITY OF WINTER SPRINGS, FLORIDA
400 NORTH EDGEMON AVENUE
WINTER SPRINGS. FLORIDA 32708
Telephone 13051 327-1800
June 30, 1982
I, Richard Rozansky, City Manager of the City of Winter
Springs, Florida, certify that the Winter Springs Fire
Department and the City of Winter Springs, Florida, are
one and the same.
n, ~
\ in
Richard Rozansky
City Manager, I
City of Winter Springs, Florida
Subscribed aud Sworn to before me at ./f;t;':fi;,) 4,_IL''lo
in the State of Florida. This 30th day of
June, 1982.
\ ,
I \
) : I 1, \
Seal
\ . i
Commission Expires
, I
a;
r-
oO
,;
..
0::
~,
o
..,.
>
>
m~
W:I:
~o
U
~
::t::
~
;;;..
P=:
o
E--
o
:to
~~
0<
zO
O~
~P=:
000
~~
2::~
O~
~W
moo
Woo
~<
U::t::
:::<
~~
...... '
><
P=:E--
~I
0'-'
~Z
~
~O
><~
E--S
W~
~Z
~~
~~
::t::~
'-'~
~~
=~
~Z
o
E--
Z
W
:t
~
Pol
W
o
APPJ"lCATlON FOR CERTIFICATE OF TITLE
.r\:-.iD/OR VEHICLE SEGISI)."RA nON
.> ~." ~TATE: OF FLORIDA '
TITLE NUMBER.
"
Owner's :\i;\lllt> .
Sex 8< DOB
Tax Stamp
L CITY OF WINTER SPRINGS
DL~
:\ddr~ss
2'400 N. EDGEMON AVE.
(Zip)
DL~
City or Town
Audit State Prey 0 R.egistered
3. WINTER SPRINGS.FL.32708
>
Herein' states th.\t ht". sht". or it is the- la.\\'ful owner of the following i
dt"scrif>ed motor \'ehic1e and nl.,kes apph'-Cltion for (CI'4ECJ\ ONE) 0
~~:~~~I;~TEEG~:T~~~~~'N B OR 80TH ~
\IAKE YEAR TYPE ~
4. WHITE 1982 -1J::. ~
Date Graded by Transaction Code
\IODEL
5 RX2-64
19
FL
STATE PREVo REGISTERED
62/23/82
i. :\hov... described vehicle- acquired by
from G
iZip)
(:'\ame)
Apphccltion will not he ;'\l.'l.:eptt:>d unless the following lien statements are ,'Ompleted.
\lWe certifv that all liens on this vehide are listed helow.
LIE:>; HOLDER
LlEl\S
If no lien write "None" above
8.
DATE OF LIEN
STREET ADDRESS
1t
A\IOUNT OF LIES
9.
CITY ,\:\D ST.\TE
^- (Zip)
.>./
lQ.
SIGNATURE
OF' \
By
(Signature of Person Signing for Applicant)
APPLlCANT(S) By
,) \RI CHARD ROZANS , CI MANAGER (Signature of Persons Signing for Applicant)
Subscri~ed\~?~ ~w\oF to be.fore me at fA !.(.4'{;....o ~A...I~
in the State of (J{C:1J~( ,~ This J:;!;.--. ~of . ~/; ,19G-
II \ \ Notary Public dYu,uq _. .?2W~~bJIC- S " - f p,~~1l at ~..
(SEAL) . ' I Date Commissio~ expires \y ommission ; 0 : A . ~~~
DEALER'S CERTIFICATE AND TRA gttrta fir. &. CasoraUy C;mp.:y
,
I hereby certify that the motor veh~ described above. is a new~d:;;;:;;:~acquired by me from
<:;:~L>>A'lJION C:Af~LiL~ :.r i.U_
11.:l3 ..si,fJl!'<. D.l:2. . (Manufacturer. Distnb70r Former Owner)
~ N.a~O VA ~~/.z.. and hereby transfer all my rights, title and
J (Address)
interest in the said vehicle toe?, 4~ ~M'N!JI!I.J;A.I..Nt:L- ,MAd~'P..s;~AI&.r... ~
iDealer or Purchaser) (Address)
I hereby warTanttille to the said vehicle and certify there are no existing liens eXl'ept as shown in this application. I further certify that the
sales tax imposed by Chapter 212. Florida Statutes. upon this vehicle has been paid by the purchaser thereof.
Amount Sales Tax Collected $' "/A Sales Tax Reg. No. H/A
D"'l.-GR~ -5t..~.~".
Bif . . __ '. --1.. . De.I" Li~'n" No.)( 3:J. 1> - t- 7 'I
'.
DR-41.A.
Rev. 40-1-76-, "
/ ..
NOTE: Purchasers holding. Certificate of Exemption, such as state agencies, counties, etc., or when
vehicle is used for rental exclusively should use this form. The purchase of motor vehicles to be offered
for rent as living accommodations does not qualify for exemption.'
~ ..
CERTIFICATE' OF MOTOR VEHICLE SALES TAX EXEMPTION
Date ~ ~1/p~
I certify the motor vehicle described below has been purchased by:
Check One
-A person holding sales tax certificate of exemption.
-A business for use exclusively for rental purposes.
and is exempted from the sales tax imposed by chapter 212, Florida Statutes.
WHITE
1982
Make
Year
Type
1WXDCHUF1CN052049
RX2-64
Engine or J.D. Kumber
Motll'l
Grumman Emergency Products, Inc.
1723 Seibel Dr.,N.E.
Roanoko,Va.2~012
Atltlrl'RS
Kame of SpHer
1.
CITY OF WINTER SPRINGS
Agl'ncy or Organization
By
400 N.EDGEMON AVE.
Address WINTER SPRINGS,FL.32708
04-00195-00-69
Cprtiflcate of Enmption No.
2. This space to be completed by purchaser of vehicle to be used for rental purposes:
NOTE: The purchase of motor vehicles to be offered for rent as living accommodations does not qualify
for exemption.
Sail'S Tax Reglstrntion No.
tiE" Tag No.
By
Firm Name
Atldress
I
I
I
!
I
,
II
I
I
,
---- -nJ:uri:J I nA Ilvn ~TTl"'""KI c
, .
.1
STATE O.:'FLORIDA'
DHSMV.Y 40-A (~!81)
\. APPLICATION FOR CERTIFICATION OF TITLE ANDIOR
o O~}41 OOOtbQtE ~~~~I~~OO
11.35
MOTOR YEHICLE SALES AND USE TAX REPORT
, -n
rJr
o Transfer of Title
o Replacement TaglDecal
Action
Requested:
~ Original Title
o
Duplicate Title
I'.... .:.... .AL NUM~ DECAL ~ BIRTHDATE EXPIRES
<. -.~,>';;'j[.;;,.....,.3,;,,<'" YR ISSUED ~ ~AY YR
'''~~~H. .* .<... [!J ~ _ ..;MI"
.TlTLE NUMBER VEHICLE IDENTIFICATION NO.
XIICrlUf. 1 CWJ:'L04',..
.WHEN VALIDATED BY THE COUNTY TAX COLLECTOR
@
.,
V
A i
L
I
10 = COilE
T
I
0
68 = co~
:L3:,::>'
TITLE =
~~~~E 21690251.
,".:::"'-"
OWNER TRANS TAG
IDENT CODE TFR FEE ISSUED
IILrry I D D D ~
M~~E WT/LENGTH CLASS GVVV/LOC/CAP
I ~ 14~~4() I 0 I I
II
OWNER'S NAME AND ADDRESS
000032708
TAX S JOTS
4.00 I LJ I
STATE PREV REG. AT6~~~fJ2a'D
&
MAKE
IWH! r
TYPE
TK
A
01 = AGR'~
.E'
A
0: 26 =~. Rll~
REV ISS {in
II
1st OWNER OIL NO
2nd OWNER OIL NO.
II
INSURANCE
LIABILITY
D
MOS
DI
BACK TAX S
SYC. CHG
~
OTHER CHARGES S TOTAL S
6.lOll 11. 35 I
PIP
D
I
DATE ISSUED
MO DAY YR
~
CREDIT VEHICLE
MO CLASS WEIGHT
cr:=J
SALES TAX
$
Z ADDRESS:
W
:J
DATE OF LIEN,
CITY - STATE
ZIP CODE:
t!~1j~M~1-1EFfEA~Wffi.:~ecl~US~~~ff1 I NC
ADDi'lESS
1723 SEIBEL DR NE
LU
C/)f-
=>0:
00
za.
<(~
tBx
.J<(
<(f-
C/)
CITY - STATE
-':OANOKE, VA
ZIP CODE
000024012
$
GRANDIOl~~5
00541
19
w
()
<(f-
.Jz
a.w
~::E
THE LICENSE PLATE AND/OR DECAL IDENTIFIED HERE
HAS BEEN LOST. STOLEN. DESTROYED OR DEFACED.
AND THE POLICE OR SHERIFF HAS BEEN NOTIFIED.
DEFACED ITEMS ARE HEREWITH SURRENDERED.
DECAL NUMBER:
TAG NUMBER:
YEAR:
VEHICLE
USAGE
~ ~-. Nf!J
, RM
'0
RBlT
o
FOR HIRE TAXI.CAB
DO
POLICE
o
U.DRIVE.fT
o
I~JO'CA.TE TOTAL PURCH~~E PRiCe:. !NCLUD'NG
ANY G,'jDAID BALANCE DU~ SELLER. BANK CR
OTHERS.
INDICATE SALES OR USE TAX DUE AS PROVIDED
BY CHAPTER 212, FLORIDA STATUTES.
$
$
CONSUMER EXEMPTION CERTlF.::
00-400195-00-69
!
TRANSFER OF TITLE
IS EXEMPT FROM
FLORIDA SALES OR
USE TAX FOR THE
REASON(Sl CHECKED:
NAME OF DEALER:
rxl PURCHASER HOLDS VALID
L.J EXEMPTION CERTIFICATE
D EVEN TRADE DINHERITANCE
D TRANSFER TO OR FROM HUSBAND OR WIFE
z
o
o:i=
w<(
...Ju
<(-
w!:!::
Of-
0:
w
U
ADDRESS:
DATE OF SALE:
CITY - STATE
ZIP CODE:
INDICATE MANUFACTURER. DISTRIBUTOR
OR FORMER OWNER IN THE SPACE PROVIDED
IN "SALES AND USE TAX REPORT" BLOCK.
DEALER
SIGNATURE
NOTE:
DYEHICLE WILL BE
USED EXCLUSIVELY
FOR RENTAL
D ORDER OF COURT IN DIVORCE PROCEEDINGS
D OTHER (EXPLAIN)
DGIFT (B~O ~~~~~D)
I HEREBY TRANSFER ALL MY RIGHTS. TITLE AND
INTEREST IN THE ABOVE DESCRIBED VEHICLE TO
THE ABOVE NAMED OWNER I ALSO WARRANT
TITLE TO THE SAID VEHICLE AND CERTIFY
THERE ARE NO EXISTING LIENS. EXCEPT AS
SHOWN IN THIS APPLICATION I CERTIFY THAT
THE SALES TAX IMPOSED BY CHAPTER 212.
FLORIDA STATUTES. UPON THIS VEHICLE HAS
BEEN PAID BY THE PURCHASER THEREOF.
SALES TAX COLLECTED
$
SALES TAX REGISTRATION ::
DEALER LICENSE =
X
IIWE HEREBY CERTIFY THAT IIWE LAWFULLY OWN THE ABOVE DESCRIBED MOTOR VEHICLE AND MAKE APPLICATION FOR TITLE AND/OR
REGISTRATION, FURTHER CERTIFYING THAT A PHYSICAL EXAMINATION OF THE VEHICLE HAS BEEN MADE AND THAT THE INFORMATION
DESCRIBING IT HEREIN IS CORRECT. I/WE AFFIRM UNDER PENALTY OF PERJURY THAT THE INFORMATION HEREIN IS TRUE AND CORRECT
TO THE BEST OF MY/OUR KNOWLEDGE AND BELIEF. IF APPLYING FOR DUPLICATE TITLE IIWE CERTIFY THAT THE PREVIOUSLY ISSUED.
TITLE HAS BEEN LOST OR DESTROYED. .
z
,...0
zi=
.:t: <(
ou
::iu::
0..-
o..f-
<(0:
W
U
SIGNATURE
OF
APPLICANTS
-BY
-BY
NOTARY SEAL
SWORN AND SUBSCRIBED TO BEFORE ME
.,'
THIS
f
, 24
DAY
OF
MAY
8"
19~
(NO T ARV PUBLICI
-IF POWER OF ATTORNEY IS USED, IT ALONG WITH ALL SUPPORTING DOCUMENTS MUST BE ATTACHED!
MY COMMISSION EXPIRES
DMV COPY /
-----.---------~--------------~