71A101 (05-16) Commonwealth of Kentucky MOTOR VEHICLE ...
71A101 (05-16)
Commonwealth of Kentucky DEPARTMENT OF REVENUE
MOTOR VEHICLE USAGE TAX MULTI-PURPOSE FORM
SECTION A
Date__________________
Plate Number _________________________ Title Number ________________________________________________
Vehicle Identification Number (VIN) __________________________________________________________________
Registration County _________________________Year ______________ Make _____________ Model __________
Registration Applicant's Name _______________________________________________________________________
(Signature required in applicable section of form for proper completion.)
The Department of Revenue may deny the exemption claimed if form is incomplete or requested documentation is not submitted. Applicant(s) will be liable for any additional tax, plus applicable penalty and interest.
SECTION B
Spouse/Spouse (Step) Parent/(Step) Child Grandparent/Grandchild
I, __________________,_________________________ , am the __________________ of __________________________ .
R
(Printed Name)(Signature)
(Relationship)
(Name)
E
L
I, __________________,_________________________ , am the __________________ of __________________________ .
A
(Printed Name)(Signature)
(Relationship)
(Name)
T
I, __________________,________________________ , am the ___________________ of __________________________ .
I
(Printed Name)(Signature)
(Relationship)
(Name)
O
N I, __________________,________________________ , am the ___________________ of __________________________ .
(Printed Name)(Signature)
(Relationship)
(Name)
All Persons Involved in a Multi-line Transfer Must be Kentucky Residents.
SECTION C
Under penalties of perjury, I __________________________________________ , _______________________________ ,
(Name)
(Grade)
___________________________ , and am stationed in Kentucky at _______________________________ on active
(Service Number)
(Military Base)
military duty under orders of the United States Government.
M I
Kentucky Resident
L
Documentation showing duty in the Commonwealth under U. S. Government orders must be attached.
I
Non-resident military
T
Copy of Current Leave Earning Statement (less than 120 days old) must be attached.
A
R
Y
(Signature of Serviceperson Claiming Exemption)
(Date)
(Applicable to military personnel stationed in Kentucky who purchase a vehicle from Kentucky dealers only.)
KRS 190.990(5) provides that any person who willfully and fraudulently submits a false statement as to the total and actual consideration paid for a motor vehicle is guilty of a Class D felony and subject to a fine of not less than $2,000 per offense.
SECTION D
Complete this section for all transactions involving modified vehicles and those to which major equipment
has been added, if not using Form 71A100 and or TC 96-182. This form will not be accepted without proper
M documentation (contract, bill of sale, front and back of cancelled check, etc.).
O
D I
When using this form, taxable value of the modified, customized or converted vehicle shall not be less than the retail value shown in the price reference manual for the vehicle without the modification.
F
I E D
Box/Flatbed Tank/Sprayer Packer/Garbage
Bus/Limousine Bucket/Lift/Cherry Picker Drill Body/Winch
O R
Custom Truck/Van Dump/Mixer Wrecker/Rollback
Ambulance/Hearse Other*
C
O
Purchase Price $_______________________
N
V
If "Other," specify________________________________________ Revenue Code Number________________________
E R
*Those vehicles not listed in the prescribed reference manual, and those not modified, customized or converted, must have a Revenue Code Number accompanying this form.
T
E
D
(Signature of Person Claiming Exemption)
(Date)
H A E N Q D U I I C P A M P E P N E T
D
SECTION E The portion of the retail price attributable to equipment or adaptive devices placed on new motor vehicles to facilitate or accommodate handicapped persons is exempt from motor vehicle usage tax. Documentation of amount paid for such equipment or adaptive devices must be submitted with this certification.
Price Without Trade or Before Trade $__________________________________________________________________
Portion of Price Attributable to Handicapped Equipment or Adaptive Devices $___________________________
(Signature of Person Claiming Exemption)
(Date)
Please Note: For those vehicles whose values are not found in the prescribed price reference manuals, contact the Motor Vehicle Usage Tax Section at (502) 564-4455.
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