Form 71a101 - Motor Vehicle Usage Tax Multi-Purpose Form Page 2
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1
2Is vehicle modified or converted?
Yes
No
(If yes, Section D must be completed.)
M
SECTION D
O
D
KRS 190.990(5) provides that any person who willfully and fraudulently submits a false statement as to the
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total and actual consideration paid for a motor vehicle is guilty of a class D felony and subject to a fine of
F
not less than $2,000 per offense.
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Owners of one ton trucks or larger, vans and modified vehicles must complete this section if not using
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Form 71A100. This form will not be accepted without proper documentation (contract, bill of sale, front
D
and back of cancelled, etc.). When using this form, taxable value of the modified, customized or
converted vehicle shall be less than the retail value shown in the price reference manual for the vehicle
without the modification.
O
R
Ambulance/Hearse
Drill Body/Winch
Stake/Flatbed
Box Added
Dump/Mixer
Tank/Sprayer
C
O
Bucket/Lift/Cherry Picker
Limousine
Wrecker/Tow Truck
N
Bus
Packer/Garbage
Other
V
Custom Truck/Van
Rollback
E
R
T
If “Other”, specify
_____________________________________________________________________________
E
_____________________________________________________________________________________________
D
H
E
A
SECTION E
Q
N
U
The portion of the retail price attributable to equipment or adaptive devices placed on new motor vehicles to
D
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facilitate or accommodate handicapped persons is exempt from motor vehicle usage tax. Documentation of
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amount paid for such equipment or adaptive devices must be submitted with this certification.
P
C
M
A
E
P
Price Without Trade or Before Trade $ ______________________________________________________________
N
P
T
E
Portion of Price Attributable to Handicapped Equipment or Adaptive Devices $ ______________________________
D
S
I
G
N
Signature ____________________________________________________________________________________
A
T
U
Printed Name _____________________________________________________
Date _____________________
R
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Please Note: For those vehicles whose values are not found in the price reference manuals provided to
each county clerk’s office, contact the Motor Vehicle Usage Tax Section at (502) 564-4455.
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