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The undersigned hereby claims exception or exemption on the purchase of the following described motor vehicle, off-highway motorcycle, or all-purpose vehicle purchased from:
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|name of vendor/seller |vendor’s license number, if any |
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|street address |city, state, ZIP code |
|Motor Vehicle, Off-Highway Motorcycle, or All-Purpose Vehicle: |
|Year: |Make: |Model: |Body Type: |
|Vehicle Identification Number (VIN): |
|Purchase Price: $ |
|And further certifies that this claim is based upon the purchaser’s proposed use of the motor vehicle, off-highway motorcycle, or all-purpose vehicle purchased, |
|the activity of the purchaser, or both, as shown hereon (purchaser must state prescribed reason for claiming exception or exemption): |
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|Purchaser’s Name |
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|Purchaser’s Activity, i.e., manufacturer, public utility, church, etc. |
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|Purchaser’s street address |
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|City, state, ZIP code | |
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|By -- Signature |Title |
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|Date signed |Vendor’s license, if any |
To be prepared in triplicate. Original to be retained by the vendor with two copies to the Clerk of Courts.
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Certificate of Exemption Regarding Sale of a Motor Vehicle, Off-Highway Motorcycle,
or All-Purpose Vehicle
STEC-MV
Rev. 3/15/04
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