Affidavit in Support of a Claim for
Exemption from Sales or Use Tax for
a Motor Vehicle Transferred By a Business Entity
Please read the instructions below before completing this form and provide the following information.
All entries must be printed or typed except for signatures.
This claim for exemption is based on the transfer of a motor vehicle to or from a business entity.
Motor Vehicle Transferred:
Vehicle identification number
, an authorized representative of
certify that the above-described motor vehicle was transferred to
and such transfer
is exempt from taxation because the transfer was pursuant to (check one):
a transaction which qualifies as a “reorganization” within the meaning of Internal Revenue Code, section 368(a)(1).
Date of reorganization
the formation of a partnership or corporate trust, or the organization of a corporation, solely in exchange for an ownership interest in the enterprise.
Date of formation
a sale or transfer to an owner of a business entity solely in exchange for the owner’s interest on the complete dissolution of a partnership or corporate
trust, or the complete liquidation of a corporation.
Date of dissolution or liquidation
I declare under the pains and penalties of perjury that I have reviewed this affidavit and the statements I have made in it and declare that they
Authorized representative of transferor
Authorized representative of transferee
The purchaser of a motor vehicle acquired for use, storage or
Please note that your statements are to be made under the pains
other consumption in the Commonwealth of Massachusetts is
and penalties of perjury and that a statement which is made will-
required to pay a sales or use tax unless an exemption is specifi-
fully and is false as to a material matter may be punished as a
cally provided for in the Massachusetts General Laws or the
felony under Massachusetts General Laws, Chapter 62C, sec-
Code of Massachusetts Regulations.
tion 73, or Chapter 268, section 1A. Perjury is a serious crime
and punishment can be severe.
An exemption from the sales or use tax for certain transfers of
motor vehicles to or from business entities is provided for by the
If you have any questions about the acceptance or use of this
Massachusetts regulations and statutes. In order to be exempt
affidavit, please contact:
from the sales or use tax you must meet the requirements of the
Massachusetts Department of Revenue
law and complete the affidavit above. You must fill in all blanks
Customer Service Bureau
and print your entries, except at the end of the affidavit where
PO Box 7010
your signature is required.
Boston, MA 02204
Note: If a final determination letter from the Internal Revenue
Service has been issued with respect to the transaction, the letter
must accompany this affidavit.
This form is approved by the Commissioner of Revenue and may be reproduced.