Form HSMV74039 "Authorization to Pay Security" - Florida

This "Form Hsmv74039 "authorization to Pay Security" - Florida" is a part of the paperwork released by the Florida Department of Highway Safety and Motor Vehicles specifically for Florida residents.

The latest fillable version of the document was released on December 1, 2015 and can be downloaded through the link below or found through the department's forms library.

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Download Form HSMV74039 "Authorization to Pay Security" - Florida

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Division of Motorist Services
Terry L. Rhodes
2900 Apalachee Parkway
Executive Director
Tallahassee, Florida 32399
Robert Kynoch
www.flhsmv.gov
Division Director
Authorization to Pay Security
Case Number
I,
hereby authorize the Bureau of Motorist
Compliance to release my $________ security deposit to _______________________________.
This deposit was made in accordance with Section 324.051 and Section 324.061, Florida
Statutes, with respect to claims for injuries to person or property resulting from an automobile
crash on ______________ in or near________________________________________________.
I further authorize and request that this payment be forwarded to
at____________________________________________________________________________.
(Signature of Depositor)
IN THE PRESENCE OF:
(Signature of Witness)
(Address)
(Signature of Witness)
(Address)
STATE OF FLORIDA
COUNTY OF
The foregoing instrument was acknowledged before me this
day of
20
, by
, who is personally known to me or
who has produced a
as identification and who did
(did not) take an oath.
(Signature)
Notary’s Name
Notary Public, State of Florida
(Form must be completed in the presence of two witnesses or a Notary Public.)
HSMV 74039 (Rev 12/15)
Division of Motorist Services
Terry L. Rhodes
2900 Apalachee Parkway
Executive Director
Tallahassee, Florida 32399
Robert Kynoch
www.flhsmv.gov
Division Director
Authorization to Pay Security
Case Number
I,
hereby authorize the Bureau of Motorist
Compliance to release my $________ security deposit to _______________________________.
This deposit was made in accordance with Section 324.051 and Section 324.061, Florida
Statutes, with respect to claims for injuries to person or property resulting from an automobile
crash on ______________ in or near________________________________________________.
I further authorize and request that this payment be forwarded to
at____________________________________________________________________________.
(Signature of Depositor)
IN THE PRESENCE OF:
(Signature of Witness)
(Address)
(Signature of Witness)
(Address)
STATE OF FLORIDA
COUNTY OF
The foregoing instrument was acknowledged before me this
day of
20
, by
, who is personally known to me or
who has produced a
as identification and who did
(did not) take an oath.
(Signature)
Notary’s Name
Notary Public, State of Florida
(Form must be completed in the presence of two witnesses or a Notary Public.)
HSMV 74039 (Rev 12/15)
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