Florida HSMV Form 74036 – Release & Monthly Repayment Note – If your Florida driver license has been suspended under the state’s Financial Responsibility Law after an at-fault crash, Form HSMV 74036 (Agreement for Release and Monthly Repayment Note) may help you restore your driving privileges. This official Florida Department of Highway Safety and Motor Vehicles (FLHSMV) form allows the at-fault driver and the other party (or parties) to agree on installment payments for property damage or bodily injury claims instead of posting a full security deposit or obtaining a full release.
This guide explains what the form is, when it is required, how to complete it correctly, and where to submit it. All information is based on current FLHSMV resources and Florida Statutes Chapter 324.
What Is Florida HSMV Form 74036?
HSMV Form 74036 is the official “Agreement for Release and Monthly Repayment Note” issued by the Florida Department of Highway Safety and Motor Vehicles. The current revision is dated 06/13. It is a two-page legal document used when a suspended driver and another party involved in a motor vehicle crash agree that the suspended driver will repay damages through scheduled monthly (or other frequency) payments.
The form serves two main purposes:
- It creates a written repayment agreement between the parties.
- It provides FLHSMV with acceptable proof that the suspended driver has made arrangements to satisfy claims arising from the crash, which can help clear a Financial Responsibility (FR) suspension.
Important note from the form itself: Only one form per releaser (other party) will be accepted. If multiple parties sustained damage or injury, a separate Form 74036 is required for each.
You can download the official English version of the form here: Download Florida HSMV Form 74036 (PDF).
When Do You Need Form 74036?
Form 74036 is typically required in the following situation:
- You were involved in a crash in Florida and were found (or charged as) at-fault.
- You did not have the required liability insurance in effect on the date of the crash.
- FLHSMV has issued (or is about to issue) a Financial Responsibility suspension of your driver license and/or vehicle registration under Chapter 324, Florida Statutes.
- You prefer to arrange installment payments with the other party rather than:
- Paying a full security deposit to FLHSMV, or
- Obtaining a full release of all claims using HSMV Form 74014.
According to FLHSMV, the Agreement for Release and Monthly Repayment Note allows the at-fault party to make arrangements for an agreed-upon repayment amount until the claim is paid in full. If the at-fault party later defaults, FLHSMV does not automatically re-suspend the license; the other party must pursue a judgment in court.
This form is commonly used alongside an SR-22 insurance filing when bodily injury is involved.
Key Differences: Form 74036 vs. Form 74014
| Feature | HSMV 74036 (Repayment Agreement) | HSMV 74014 (Full Release) |
|---|---|---|
| Purpose | Installment payments agreed upon | Claim paid in full; complete release of all claims |
| When to Use | You will pay over time | You have already paid everything owed |
| Notarization | Required for both parties | Required |
| Default Consequence | Other party may seek court judgment (possible future suspension) | None (claim already satisfied) |
Choose Form 74036 only when both parties genuinely agree to a payment plan.
How to Complete Florida HSMV Form 74036 Step by Step?
Accuracy is critical. Incomplete or incorrect forms are routinely rejected by FLHSMV or tax collector offices.
- Suspended Driver’s Personal Information
Enter your full legal name (Last, First, Middle Initial, Suffix), current mailing address, city, state, ZIP code, date of the crash, date of birth (MM/DD/YY), Florida driver license number, Social Security number, Financial Responsibility case number (found on your suspension notice), and location of the crash. - Name and Address of the Other Party (Releaser)
List the name and address of the person or business receiving the payments. Use a separate form for each releaser. - Terms of Agreement
Check the appropriate box(es):- Property Damage for: (describe)
- Bodily Injury Liability for: (describe)
Enter the Total Amount agreed upon, Date of First Payment, and Frequency of Payment (monthly, bi-weekly, etc.).
- Signatures and Notarization
Both the suspended driver and the other party (or authorized representative such as an insurance company, attorney, or subrogee) must sign. The form clearly states: “Signatures Below Must Be Notarized” and “Release is VOID unless all signatures are notarized.” Each signature requires its own notary acknowledgment with seal.
Keep a copy of every completed form for your records.
Instructions for Submitting Form 74036
Official FLHSMV instructions included with the form state:
- Make copies of the form and mail one to each releaser on your list using certified mail, Return Receipt Requested.
- If the releaser signs and returns the form, take the signed releases plus your original SR-22 (if required) to your nearest Florida driver license office or mail them to the address below.
- If the releaser refuses to sign or does not respond, you must post the security deposit associated with that person.
- If mail is returned undeliverable, you may be able to reduce the deposit amount ($100 for bodily injury and/or $250 for property damage) by presenting the sealed envelope at a local office.
Mailing Address:
Department of Highway Safety and Motor Vehicles
Bureau of Motorist Compliance, MS 98
Post Office Box 5775
Tallahassee, Florida 32314-5775
Phone: 850-617-2000
Fax: 850-617-5216
You may also submit the completed, notarized form in person at a local tax collector office or FLHSMV service center. Appointments are often required.
Important Legal Notes and Limitations
- The form is a compromise of doubtful and disputed claims. Signing does not admit liability beyond the agreement terms.
- If any installment is missed, the entire unpaid balance becomes due at the election of the other party, and the suspended driver may be responsible for collection costs and reasonable attorney fees.
- Default on the agreement does not automatically trigger a new FLHSMV suspension. The other party must obtain a court judgment before FLHSMV can act on the unpaid balance.
- Once the total amount is paid in full, the suspended driver receives a release from any and all other claims arising from the crash under the terms of the agreement.
- If you have already been compensated by your own insurance company, consult your insurer or an attorney before signing. Subrogation rights may be affected.
Related Forms and Resources
- HSMV 74014 – Release in Full of All Claims (use when the claim is paid completely)
- HSMV 74036SP – Spanish version of the Agreement for Release and Monthly Repayment Note
- FLHSMV – Involved in a Crash? (official guidance)
- Official FLHSMV Forms Page
- Find a Local FLHSMV or Tax Collector Office
Frequently Asked Questions
Is Form 74036 available as a fillable PDF?
Yes. The official version on the FLHSMV website can be filled electronically in most PDF readers, printed, and then signed and notarized.
Can I use this form for a judgment that has already been entered?
No. For existing judgments, different forms (such as HSMV 74034 Judgment Consent Form or HSMV 74038 Satisfaction of Judgment) are used.
How long is the security deposit held if I cannot obtain releases?
Deposits are generally held for one year. After 11 months, FLHSMV mails instructions for requesting a refund. You have up to five years from the deposit date to claim it.
Do I still need SR-22 insurance?
In most cases involving bodily injury or when required by the suspension notice, yes. Form 74036 alone does not replace the SR-22 requirement.