Motor Vehicle Usage Tax Multi-Purpose Form - Kentucky Department Of Revenue Page 2
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2KRS 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
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documentation (contract, bill of sale, front and back of cancelled check, etc.).
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When using this form, taxable value of the modified, customized or converted vehicle shall not be less than the
D
retail value shown in the price reference manual for the vehicle without the modification.
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F
I
Box/Flatbed
Bus/Limousine
E
Tank/Sprayer
Bucket/Lift/Cherry Picker
D
Packer/Garbage
Drill Body/Winch
Custom Truck/Van
Ambulance/Hearse
O
Dump/Mixer
Other*
R
Wrecker/Rollback
C
O
Purchase Price $_______________________
N
If “Other, ” specify _______________________________________ Revenue Code Number _______________________
V
E
*Those vehicles not listed in the prescribed reference manual, and those not modified, customized or
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converted, must have a Revenue Code Number accompanying this form.
T
E
D
(Signature of Person Claiming Exemption)
(Date)
SECTION E
H
The portion of the retail price attributable to equipment or adaptive devices placed on new motor vehicles to
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A
facilitate or accommodate handicapped persons is exempt from motor vehicle usage tax. Documentation of
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N
amount paid for such equipment or adaptive devices must be submitted with this certification.
U
D
I
I
P
Price Without Trade or Before Trade $ _________________________________________________________________
C
M
A
E
P
Portion of Price Attributable to Handicapped Equipment or Adaptive Devices $ __________________________
N
P
T
E
D
(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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