Form 15st - Affidavit Of Gross Retail And Use Tax
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1INDIANA
INDIANA
AFFIDAVIT OF GROSS RETAIL
AFFIDAVIT OF GROSS RETAIL
DEPARTMENT OF
DEPARTMENT OF
AND USE TAX
AND USE TAX
REVENUE
REVENUE
State Form 41806 (R2 / 5-97) / BMV Form 15ST
State Form 41806 (R2 / 5-97) / BMV Form 15ST
Name of seller
Name of seller
Address of seller (number and street or Rural Route)
Address of seller (number and street or Rural Route)
City
City
State
ZIP code
State
ZIP code
Name of purchaser
Name of purchaser
Date of sale (month, day, year)
Date of sale (month, day, year)
Body type
Vehicle / Watercraft make
Body type
Vehicle / Watercraft make
Vehicle / Watercraft year
Vehicle / Watercraft year
Identification number
Identification number
Model number
Model number
Year of trade-in
Year of trade-in
Selling price of vehicle / watercraft
Selling price of vehicle / watercraft
$
$
Make of trade-in
Make of trade-in
Value of trade-in vehicle / watercraft
Value of trade-in vehicle / watercraft
$
$
Total price paid
Type of trade-in
Total price paid
Type of trade-in
$
$
I hereby verify under the penalty of perjury that the total price paid for the above described vehicle
I hereby verify under the penalty of perjury that the total price paid for the above described vehicle
/ watercraft represents the true amount collected for the sale of the vehicle / watercraft. This
/ watercraft represents the true amount collected for the sale of the vehicle / watercraft. This
statement is made for the purpose of providing a value for use by the Indiana Department of
statement is made for the purpose of providing a value for use by the Indiana Department of
Revenue in determining the purchaser's sales (use) tax.
Revenue in determining the purchaser's sales (use) tax.
Date (month, day, year)
Date (month, day, year)
Signature of seller
Signature of seller
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