Form 71a103 - Application For Protective Refund Of Motor Vehicle Usage Tax Used Vehicles Purchased Out-Of-State Page 2

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AFFIDAVIT
I, ___________________________ purchased a used ___________________________(year, make, model) from
an out-of-state dealer on ____________________________.
The motor vehicle dealer’s name is: _____________________ and is located in _______________________ (city)
______________________ (state).
I traded-in a used ____________________________ (year, make, model).
I the undersigned hereby declare under penalties of perjury that the foregoing affidavit, including any accompanying
statements, is true and accurate to the best of my knowledge.
Signature _________________________________________
Printed name_______________________________________
Date signed _______________________________________

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