Form 5010 - Certificate To Establish Out-Of-State Delivery Of Motor Vehicle To Nonresident - Arizona Department Of Revenue Page 2

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This section is fillable.
PURCHASER INFORMATION:
PURCHASER’S NAME (PLEASE PRINT):
DRIVER’S LICENSE NO.:
STATE:
ADDRESS:
CITY STATE ZIP:
You may now print your form; click the blue print button.
PURCHASER CERTIFICATION:
I certify, under penalty of perjury under the laws of the State of Arizona, that I personally accepted
delivery of the above vehicle at the delivery address indicated on page 1, and that this vehicle is
purchased for use outside of Arizona.
SIGNATURE OF PURCHASER OR REPRESENTATIVE
DATE OF DELIVERY
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NOTARY STATEMENT
State of
County of
On this
day of
, 20
, before me personally appeared
NOTARY SEAL
, whose identity was proved to me on the
(PURCHASER OR REPRESENTATIVE)
basis of satisfactory evidence to be the person whose name is subscribed to this
document and who acknowledged that he/she signed the above document.
Notary Signature:
SELLER:
Remit a copy of this form, and all other executed Form 5010’s, to the Arizona Department
of Revenue on a quarterly basis. Attach the associated Form 5011 or Form 5012 to each Form 5010
submitted. (See TPP 08-1 and Form 5010Q).
Mail to:
NONRESIDENT MOTOR VEHICLE PROGRAM - TPT AUDIT DIVISION
ARIZONA DEPARTMENT OF REVENUE
1600 W. MONROE, ROOM 620
PHOENIX, AZ 85007
ADOR 60-5385f (9/08)

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