APPLICATION FOR GOVERNMENTAL SERVICES TAX EXEMPTION

555 Wright Way Carson City, NV 89711-0700 Reno/Sparks/Carson City (775) 684-4DMV (4368) Las Vegas area (702) 486-4DMV (4368)



APPLICATION FOR GOVERNMENTAL SERVICES TAX EXEMPTION

(Nevada Tribal Members Residing on Reservation within the Boundaries of Nevada)

Instructions: This application for exemption must be submitted for each registration period. Separate applications are required for each vehicle. The application for exemption must be presented at the time of registration or renewal. A Tribal Chair of a Nevada Indian Tribe must certify that the applicant meets the eligibility criteria for Governmental Services Tax exemption.

Eligibility: The registered owner of the vehicle must be a member of a recognized Nevada tribe. The vehicle must be located (based) on Nevada tribal land. The physical address for the vehicle registration must be located on tribal land within the boundaries of the State of Nevada.

Please Print or Type

Vehicle Year _____________________ Make ___________________________________________

Model ___________________________ License Plate Number______________________________

Vehicle Identification Number:

Full Legal Name

Last

First

Middle

Nevada Driver's License, Identification Card Number, or Date of Birth _________________________________________

Physical Address

Address

City

State

Zip Code

Mailing Address

Address

City

State

Zip Code

Telephone (optional) ________________________

E-mail (optional) __________________________

I declare under penalty of perjury that the foregoing is true and correct.

Executed on Date

Applicant Signature

I declare under penalty of perjury that the forgoing is true and correct and that the applicant meets the eligibility requirements listed above.

Tribal Chairman's Name (Print)

Tribal Agency

________________________________________________________________________________________________

Tribal Chairman's Signature

Date

For DMV Use Only Technician Number: _________ Super Trans. Number:____________ Date: _________ Exemption Amount: $ _________

VP154 (Rev. 11-2014) Signatures must be originals. Photocopies are not acceptable. Changes may not be made to this form once it is signed.

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