STATE OF FLORIDA
STATE OF FLORIDA
DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES - MOTORIST SERVICES
SUBMIT THIS FORM TO YOUR LOCAL TAX COLLECTOR OFFICE
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APPLICATION FOR REPLACEMENT LICENSE PLATE, VALIDATION DECAL
OR PARKING PERMIT ansirvaions on Reverse Side)
11 REPLACEMENT TYPE
Check applicable box below:
❑ License Plate
❑x Decal
❑ License Plate and Decal
❑ Disabled Person Long-Tern Parking Permit
❑ Disabled Person Temporary Parking Permit
❑ HOV (High Occupancy Vehicle) Decal REPLACEMENT REASON
Check applicable box below:
LI Damaged ❑ Surrendered/Seized
❑ Defaced ❑ Stolen (see back)
❑ Lost ❑ Stolen/Police Report
E Lost-in-transit (applied for and never received)
❑ Voluntary (specific reason for replacement)
Please contact your Local County Tax Collector's Office or License Plate Agent for fee information.
2 OWNER / CUSTOMER IDENTIFICATION
JEFFREY EPSTEIN
(Owners or Lessees Name)
358 EL BRILLO WAY (Driver License Number)
(Street Address)
PALM BEACH
(City) FLORIDA 33480-4730
(State) (Zip)
3 VEHICLE / VESSEL / MOBILE HOME INFORMATION (a) 1GNSKJKC7JR222801 2018 CHEVROLET
(Vehicle / Hull / Mobile Home Identification Number)
(b)
HJGK55 00189989 (Year) (Make)
(Previous License Plate Number) (Previous DecalNumber) (Previous Parking Placard Number)
4 ATTESTMENT
I hereby certify under the penalty of perjury that the license plate, decal or permit for the vehicle, vessel, or mobile home listed
in Section 3 (a), is no longer or has never been in my possession for the reason checked in Section 1. All information herein is
true and correct to the best of my knowledge.
07 /18 / 2018
(Date) (Owner/Applicant's Signature)
Complete the following, if applicable:
(License Plate. Decal, or Parking Permit Number)
HSMV 83146 (Rev. 1/18) was surrendered to the tax collector:
(County) (Agency)
(Signature of Agency Personnel) (Date)
www.flhsmv.gov
EFTA00283078