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

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71A101 (4-05)
Commonwealth of Kentucky
MOTOR VEHICLE USAGE TAX
DEPARTMENT OF REVENUE
MULTI-PURPOSE FORM
SECTION A
Date__________________
Plate Number _________________________ Title Number ________________________________________________
Vehicle Identification Number (VIN) __________________________________________________________________
Registration County _________________________ Year ______________ Make _____________ Model __________
Registration Applicant’s Name _______________________________________________________________________
(Signature required on back of form for proper completion.)
SECTION B
E
EXEMPTION CLAIMED PER KRS 138.470
X
E
Charitable/Education*
U.S./State/Local Government*
T
M
Military Exempt*
Husband/Wife
Y
P
P
(Step)Parent/(Step)Child/Grandparent/Grandchild
Name Change*
T
E
Corporation/Proprietorship (LLC)*
Court Order/Will*
I
Corporation/Subsidiary (LLC)*
LLC/Members*
O
Repossession*
Redeemed*
N
*Documentation must be provided. Exemption cannot be claimed without all requested information.
I, __________________,_________________________ , am the __________________ of __________________________ .
(Printed Name)
(Signature)
R
(Relationship)
(Name)
E
I, __________________,_________________________ , am the __________________ of __________________________ .
L
(Printed Name)
(Signature)
(Relationship)
(Name)
A
T
I, __________________,________________________ , am the ___________________ of __________________________ .
(Printed Name)
(Signature)
(Relationship)
(Name)
I
O
I, __________________,________________________ , am the ___________________ of __________________________ .
N
(Printed Name)
(Signature)
(Relationship)
(Name)
All Persons Involved in a Multi-line Transfer Must be Kentucky Residents.
SECTION C
N
O
M
Under penalties of perjury, I __________________________________________ , _______________________________ ,
N
(Name)
(Grade)
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
T
(Military Base)
I
A
Government.
D
R
E
Y
N
(Signature of Serviceperson Claiming Exemption)
(Date)
T
(Applicable to nonresidents stationed in Kentucky who purchase a vehicle from Kentucky dealers only.)
Copy of Current Leave Earning Statement Less than 120 Days Old Must be Attached

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