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Rev. 4/99

Form MVU-5A

Massachusetts

Application for Certification/Recertification to

Department of

the Motor Vehicle Leasing List

Revenue

All entries must be printed or typed, except for signatures.

Name of vendor

Telephone number

Address of vendor

City/Town

State

Zip

, certify that I am the owner and/or authorized representative of the

above-named vendor and that the vendor holds vendor registration number

–

issued by the Commissioner of Revenue and

that the vendor is engaged in Massachusetts in the business of leasing and/or renting motor vehicles.

It is further certified that all motor vehicles which are or will be registered by the vendor under this certificate are or will be used exclusively for leasing

or rental.

Please indicate the total number of motor vehicles of the vendor used for leasing/rental currently registered in Massachusetts:

Owner or authorized representative

Title

Date

Any person who willfully delivers or discloses to the Commissioner of Revenue any false or fraudulent statement shall be fined for not more than $10,000

or $50,000 in the case of a corporation, or by imprisionment for not more than one year, or both.

Motor Vehicle Leasing List Questionnaire

Definition: The term motor vehicles, as it is used in this questionnaire, relates to all motor vehicles which are or will be registered to an individual or

business on the Motor Vehicle Leasing List.

1. Does the business lease or rent motor vehicles?

Yes

No. If yes, please state type(s) of motor vehicle(s) leased or rented (check all that apply):

Automobiles

Trucks

Limousines

Taxis

Other: ____________________________________________________________________

2. Does the business lease or rent any of its motor vehicles to any of its employees?

Yes

No.

3. Please state whether the business for which certification is sought is a (check one):

Sole proprietorship

Corporation

Partnership

Trust

Other (explain): ___________________________________________________

______________________________________________________________________________________________________________________

4. Does the business lease or rent limousines? If yes, please state whether a chauffeur/driver is provided when such vehicles are leased or rented.

______________________________________________________________________________________________________________________

5. If the business is a taxi company, are the taxis used exclusively for leasing or rental on all shifts? If not, please explain briefly.

_________________________________________________________________________________________________________________________

6. Please indicate all purposes for which the exempted motor vehicles will be used (check all that apply):

Lease

Courier

Private use

Business use

Taxi

Limousine service

Funeral service

Other (explain): _______________________________________________________________________________________________________

Declaration

I declare under the pains and penalties of perjury that I have reviewed this application and the statements I have made in it and declare that

they are true.

Signature

Title

Date

Mail to: Massachusetts Department of Revenue

Customer Service Bureau

Motor Vehicle Leasing Certification

PO Box 7010

Boston, MA 02204

(617) 887-MDOR

This form is approved by the Commissioner of Revenue and may be reproduced.

Form Mvu-5a - Application For Certification-Recertification To The Motor Vehicle Leasing List

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