STATE OF FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES — MOTORIST SERVICES SUBMIT THIS FORM TO YOUR LOCAL TAX COLLECTOR OFFICE wea fibsmy qor/offices/ APPLICATION FOR REPLACEMENT LICENSE PLATE, VALIDATION DECAL OR PARKING PERMIT (Instructions on Reverse Side) 1 REPLACEMENT TYPE REPLACEMENT REASON Check applicable box below: Check applicable box below: [| License Plate {) Damaged {_| Surrendered/Seized [x] Decal |_] Defaced {_] Stolen (see back) [| License Plate and Decal [| Lost [_] Stolen/Police Report CJ Disabled Person Long-Term Parking Permit [x] Lost-in-transit (applied for and never received) |_| Disabled Person Temporary Parking Permit |_| Voluntary (specific reason forreplacement) [] 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 (Owner's or Lessee's Name) (Onver 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 fehicle / Hull / ile Home Identification Number) ear) (Make) am HJGK55 00189989 revious e umber revious jum evious Parking jum | 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 r/Applicant's ature (Date) Complete the following, if applicable: as Surrenderedtothe taxcollector: ———i—‘“‘stsCS (License Plate, Decal, or Parking Permit Number) (County) (Agency) (Signature of Agency nel) (Date) HSMV 83146 (Rev. 1/18) www fihsmv.gov EFTA00283078