Form 71a101 - Motor Vehicle Usage Tax Multi-Purpose Form Page 2
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2KRS 190.990(5) provides that any person who willfully and fraudulently submits a false statement as to the
total and actual consideration paid for a motor vehicle is guilty of a Class D felony and subject to a fine of not
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less than $2,000 per offense.
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SECTION D
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Complete this section for all transactions involving modified vehicles and those to which major equipment has
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been added, if not using Form 71A100 and or TC 96-182. This form will not be accepted without proper
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documentation (contract, bill of sale, front and back of cancelled check, etc.).
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When using this form, taxable value of the modified, customized or converted vehicle shall not be less than the
retail value shown in the price reference manual for the vehicle without the modification.
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Box/Flatbed
Bus/Limousine
Tank/Sprayer
Bucket/Lift/Cherry Picker
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Packer/Garbage
Drill Body/Winch
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Custom Truck/Van
Ambulance/Hearse
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Dump/Mixer
Other*
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Wrecker/Rollback
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Purchase Price $_______________________
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If “Other, ” specify ________________________________________________ Revenue Code Number _________________
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*Those vehicles not listed in the prescribed reference manual, and those not modified, customized or
converted, must have a Revenue Code Number accompanying this form.
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SECTION E
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The portion of the retail price attributable to equipment or adaptive devices placed on new motor vehicles to
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facilitate or accommodate handicapped persons is exempt from motor vehicle usage tax. Documentation of
amount paid for such equipment or adaptive devices must be submitted with this certification.
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Price Without Trade or Before Trade $ _________________________________________________________________
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Portion of Price Attributable to Handicapped Equipment or Adaptive Devices $ __________________________
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Printed Name _____________________________________________________________Date ____________________
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Signature __________________________________________________________________________________________
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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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