Form Mvu-33 - Affidavit In Support Of A Claim For Exemption From Sales Or Use Tax For A Motor Vehicle Transferred To A Disabled Person - Massachusetts Department Of Revenue
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1Form MVU-33
Rev. 9/11
Affidavit in Support of a Claim for Exemption
Massachusetts
from Sales or Use Tax for a Motor Vehicle
Department of
Transferred to a Disabled Person
Revenue
Please read the instructions below before completing this form and provide the following information.
All entries must be printed or typed except for signatures.
Check applicable box:
Exemption is based on a loss of two or more limbs. Complete only Part A below.
Exemption is based on a loss of use of two or more limbs. Complete both Parts A and B below.
Part A
Name of disabled person
Address
City/Town
State
Zip
I,
, of
certify that I suffer the loss of two or more limbs, or the permanent loss of use of at least 80% of each of two or more limbs. I hereby authorize the
Department of Revenue to have access to my medical records to verify this claim.
Declaration
I declare under the pains and penalties of perjury that I have reviewed this affidavit and the statements I have made in it and declare that they
are true.
Signature of disabled person or legal guardian, whichever is applicable
Date
Part B
Name of physician
Address
City/Town
State
Zip
I,
, of
Telephone number
Name of disabled person
of
certify that
Address
City/Town
State
Zip
suffers the permanent loss of use of at least 80% of each of two or more limbs.
Declaration
I declare under the pains and penalties of perjury that I have reviewed this affidavit and the statements I have made in it and declare that they
are true.
Physician’s signature
Date
Instructions
This exemption applies only to one motor vehicle which must be
Please note that your statements are to be made under the pains
owned and registered for the personal, non-commercial use of the
and penalties of perjury and that a statement which is made willfully
purchaser or transferee.
and is false as to a material matter may be punished as a felony
under M.G.L. Ch. 62C, sec. 73, or Ch. 268, sec. 1A. Perjury is a
This affidavit must accompany Form RMV-1 when submitted
serious crime and punishment can be severe.
to the Registry of Motor Vehicles.
For specific instructions affecting minors or adults who cannot
The purchaser of a motor vehicle acquired for use, storage or other
legally enter into binding contracts, see Directive 03-11.
consumption in the Commonwealth of Massachusetts is required
to pay a sales or use tax unless an exemption is specifically pro-
If you have any questions about the acceptance or use of this affi-
vided for in the Massachusetts General Laws or the Code of Mass-
davit, please contact: Massachusetts Department of Revenue,
achusetts Regulations.
Customer Service Bureau, PO Box 7010, Boston, MA 02204;
(617) 887-MDOR.
An exemption from the sales or use tax for transfers to disabled per-
sons under certain conditions is provided for by the Massachusetts
regulations and statutes. In order to be exempt from the sales or
use tax you must meet the requirements of the law and complete
the affidavit above. You must fill in all blanks and print your entries,
except at the end of the affidavit where the signature is required.
This form is approved by the Commissioner of Revenue and may be reproduced.
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