STATE OF FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES - MOTORIST SERVICES SUBMIT THIS FORM TO YOUR LOCAL TAX COLLECTOR OFFICE wave tam rra/cffne./ APPLICATION FOR REPLACEMENT LICENSE PLATE, VALIDATION DECAL OR PARKING PERMIT ansirvaions on Reverse Side) 11 REPLACEMENT TYPE Check applicable box below: K License Plate ❑x Decal K License Plate and Decal K Disabled Person Long-Tern Parking Permit K Disabled Person Temporary Parking Permit K HOV (High Occupancy Vehicle) Decal REPLACEMENT REASON Check applicable box below: LI Damaged K Surrendered/Seized K Defaced K Stolen (see back) K Lost K Stolen/Police Report E Lost-in-transit (applied for and never received) K 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