EFTA00283078.pdf

STATE OF FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES - MOTORIST SERVICES SUBMIT THIS FORM TO YOUR LOCAL TAX COLLECTOR OFFICE wave tamrra/cffne./ APPLICATION FOR REPLACEMENT LICENSE PLATE, VALIDATION DECAL OR PARKING PERMIT ansirvaions on Reverse Side) 11 REPLACEMENT TYPE REPLACEMENT REASON Check applicable box below: Check applicable box below: ❑ License Plate LI Damaged ❑ Surrendered/Seized ❑x Decal ❑ Defaced ❑ Stolen (see back) ❑ License Plate and Decal ❑ Lost ❑ Stolen/Police Report ❑ Disabled Person Long-Tern Parking Permit E Lost-in-transit (applied for and never received) ❑ Disabled Person Temporary ParkingPermit ❑ Voluntary (specific reason for replacement) ❑ HOV (High Occupancy Vehicle)Decal 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) (Driver License Number) 358 EL BRILLO WAY (Street Address) PALM BEACH FLORIDA 33480-4730 (City) (State) (Zip) 3 VEHICLE / VESSEL / MOBILE HOME INFORMATION (a) 1GNSKJKC7JR222801 2018 CHEVROLET (Vehicle / Hull / Mobile Home Identification Number) (Year) (Make) (b) HJGK55 00189989 (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 (Owner/Applicant's Signature) (Date) Complete the following, if applicable: was surrendered to the tax collector: (License Plate. Decal, or Parking Permit Number) (County) (Agency) (Signature of Agency Personnel) (Date) HSMV 83146 (Rev. 1/18) www.flhsmv.gov EFTA00283078