Form HSMV-84019 "Application and Claim to Recover Compensation From the Mobile Home and Recreational Vehicle Trust Fund" - Florida

What Is Form HSMV-84019?

This is a legal form that was released by the Florida Department of Highway Safety and Motor Vehicles - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2011;
  • The latest edition provided by the Florida Department of Highway Safety and Motor Vehicles;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form HSMV-84019 by clicking the link below or browse more documents and templates provided by the Florida Department of Highway Safety and Motor Vehicles.

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Download Form HSMV-84019 "Application and Claim to Recover Compensation From the Mobile Home and Recreational Vehicle Trust Fund" - Florida

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STATE OF FLORIDA
DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES
DIVISION OF MOTORIST SERVICES
APPLICATION AND CLAIM
TO RECOVER COMPENSATION FROM THE MOBILE HOME AND
RECREATIONAL VEHICLE TRUST FUND
INSTRUCTIONS: Type or legibly print all information, except signatures. In order to process
this application, all questions, including the sworn statement, must be properly completed.
Please complete the appropriate form for either Unsatisfied Judgment or Bankruptcy. All
documents supporting the claim must be submitted with the application in order to properly
access the claim for approval or disapproval. The completed application and supporting
documents are to be forwarded to:
Claims Administrator
Division of Motorist Services
2900 Apalachee Parkway, MS-61
Tallahassee, Florida 32399
Pursuant to section 320.781, Florida Statutes, I hereby make application and submit the required
documentation, under oath, for compensation of an unsatisfied judgment or unsatisfied claim
against a mobile home or recreational vehicle dealer or broker and/or surety. The maximum
claim that can be paid under the trust find is $25,000.
Name of Claimant
Residence address
(
)
City, State and Zip Code
Home telephone number
(
)
Business telephone number
Social Security number of Claimant
Date signed
Signature of Claimant
HSMV-84019 (Rev. 01/11)
STATE OF FLORIDA
DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES
DIVISION OF MOTORIST SERVICES
APPLICATION AND CLAIM
TO RECOVER COMPENSATION FROM THE MOBILE HOME AND
RECREATIONAL VEHICLE TRUST FUND
INSTRUCTIONS: Type or legibly print all information, except signatures. In order to process
this application, all questions, including the sworn statement, must be properly completed.
Please complete the appropriate form for either Unsatisfied Judgment or Bankruptcy. All
documents supporting the claim must be submitted with the application in order to properly
access the claim for approval or disapproval. The completed application and supporting
documents are to be forwarded to:
Claims Administrator
Division of Motorist Services
2900 Apalachee Parkway, MS-61
Tallahassee, Florida 32399
Pursuant to section 320.781, Florida Statutes, I hereby make application and submit the required
documentation, under oath, for compensation of an unsatisfied judgment or unsatisfied claim
against a mobile home or recreational vehicle dealer or broker and/or surety. The maximum
claim that can be paid under the trust find is $25,000.
Name of Claimant
Residence address
(
)
City, State and Zip Code
Home telephone number
(
)
Business telephone number
Social Security number of Claimant
Date signed
Signature of Claimant
HSMV-84019 (Rev. 01/11)
DESCRIPTION OF UNIT
Note: If the transaction resulting in this claim arose out of a consignment sale rather than a
purchase, use the date of the consignment transaction.
Date of purchase/consignment
Unit/Vehicle Identification Number (VIN)
Make of unit
Model/Year of unit
Color of unit
DEALER/BROKER INFORMATION
Dealer/Broker Name
License Number
Address of Dealer/Broker
City, State and Zip Code
SURETY COMPANY INFORMATION
Note: Be sure that the named surety bond was the correct bond in effect at the time of the
transaction, which is the subject of this claim.
Name of Surety Company
Surety Number
Address of Dealer/Broker
City, State and Zip Code
HSMV-84019 (Rev. 01/11)
UNSATISFIED JUDGMENT
If your application for claim is based on an unsatisfied final judgment against a mobile home or
recreational vehicle dealer or broker or its surety jointly and severally, or against the mobile
home dealer or broker only, where the court found that the surety was not liable due to prior
payment of valid claims against the bond in an amount equal to, or greater than, the face amount
of the applicable bond; or, if your claim is based on an unsatisfied judgment against the surety of
the mobile home or recreational vehicle dealer or broker, the following documentation must
accompany this application.
1.
A copy of the judgment. Does the judgment contain?:
a.
a list of damages,
b.
a determination of the liability of the surety company,
c.
costs,
d.
attorney fees.
2.
Evidence that Judgment or Lien has been recorded with the clerk's office.
3.
A copy of the purchase agreement or consignment agreement for the
vehicle.
4.
Documentation that substantiates the judgment against the dealer/broker
is unsatisfied.
5.
Documentation of the amount or value of recovery made thus far against
the liable party.
6.
An attestment to the amount that may be realized from the sale or assets
of the liable party.
7.
Certificate, statement, or document that claimant has made a good faith
effort to collect from the judgment. (Attach additional sheet if necessary)
8.
An assignment by claimant or rights, title or interest in the unsatisfied
judgment and judgment lien to the Department of Highway Safety and
Motor Vehicles. Assignment of Judgment, HSMV 84027, has been
executed and is attached.
Note: Claims containing incomplete documentation cannot be processed until the required
documentation has been submitted. Please include any additional information that may be of
assistance to this office in successfully processing your claim.
HSMV-84019 (Rev. 01/11)
BANKRUPTCY
If your application for claim is based on a lawsuit which has been stayed or discharged as a result
of the filing for reorganization or discharge of bankruptcy by the dealer or broker, and judgment
against the surety is not possible because of the bankruptcy or liquidation of the surety, or
because the surety has been found by the court not to be liable due to the prior payment of valid
claims against the bond in an amount equal to, or greater than, the face amount of the applicable
bond, the following information must be completed and the requested documentation must
accompany this application.
Indicate type of Bankruptcy:
Liquidation
Rehabilitation
(Reorganization)
1.
Assignment of Claim/Suit, HSMV 84026 has been executed and attached.
2.
Copy of the lawsuit filed by claimant against the dealer and/or surety
company along with a copy of all pleadings in the case.
3.
Copy of the order of the bankruptcy court staying or discharging the
proceeding.
4.
Documentation that the surety company is not liable and the reason.
5.
True copies of all sales documents, purchase agreements, notices, service
repair orders and any other documentation pertaining to the case.
6.
Actual monetary amount needed to reimburse or compensate the claimant,
supported by documentation.
7.
Allegations setting forth the facts of the complaint.
(Attach additional sheets, if necessary)
Note: Claims containing incomplete documentation cannot be processed until the required
documentation has been submitted. Please include any additional information that may
be of assistance to this office in successfully processing your claim.
HSMV-84019 (Rev. 01/11)
STATEMENT UNDER OATH
I hereby swear or affirm that the information and documentation submitted as part of this
application are true and correct and are provided as requested without reservation.
Date Signed
Signature
Printed or Typed Name of Claimant
Sworn to or affirmed and subscribed
before me this
day
of
,
My Commission Expires:
NOTARY PUBLIC
State of Florida at Large
Personally Known
Produced Identification
HSMV-84019 (Rev. 01/11)
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