Form 71a101 - Motor Vehicle Usage Tax Multi-Purpose Form

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71A101 (5-00)
Commonwealth of Kentucky
MOTOR VEHICLE USAGE TAX
REVENUE CABINET
MULTI- PURPOSE FORM
SECTION A
Date _________________
Vehicle Identification Number (VIN), Title or Plate Number _____________________________________________
Registration County _______________________________________________
Make ___________________
Model __________________
Registration Applicant’s Name _______________________________________
Year ___________________
SECTION B
E
EXEMPTION CLAIMED PER KRS 138.470
X
Charitable/Education Organization
Military Exempt*
E
Corporation/Proprietorship (LLC)*
Name Change
T
M
Corporation/Subsidiary (LLC)*
Parent/Child
Y
P
P
Court Order/Will*
Redeemed Repossession
T
E
Dealer Registration
Repossession*
I
O
Grandparent/Grandchild
State Government
N
Husband/Wife
Stepparent/Stepchild
Local Government
U.S. Government
*Documentation must be provided for Corporation/Proprietorship (LLC), Corporation/Subsidiary (LLC),
Court Order/Will, Military Exempt, Repossession.
R
I, __________________________ , am the _________________________ of __________________________ .
(Name)
(Relationship)
(Name)
E
L
I, __________________________ , am the _________________________ of __________________________ .
A
(Name)
(Relationship)
(Name)
T
I, __________________________ , am the _________________________ of __________________________ .
I
(Name)
(Relationship)
(Name)
O
N
I, __________________________ , am the _________________________ of __________________________ .
(Name)
(Relationship)
(Name)
SECTION C
N
O
Under penalties of perjury, I _______________________________________ , ______________________________ ,
M
(Name)
(Grade)
N
I
R
_______________________ , declare that I am a resident of _______________________________________ and am
L
(Service Number)
E
I
stationed in Kentucky at ______________________________ on active military duty under orders of the United States
S
(Military Base)
T
I
A
Government.
D
R
E
______________________________________________
_______________________________________
Y
N
(Signature of Serviceperson Claiming Exemption)
(Date)
T
(Applicable to vehicles purchased from Kentucky dealers only.)
Copy of Current Leave Earning Statement Must be Attached

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