Form 5095 - Sales Tax Exemption Statement For Authorized Common Carriers
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Missouri Department of Revenue
Sales Tax Exemption Statement
Form
5095
For Authorized Common Carriers
This form must be completed and submitted with each application for title in which the applicant is claiming a common carrier sales tax exemption.
Applicants who do not qualify for the common carrier tax exemption who haul loads in excess of 54,000 lbs. must complete an Application for Sales Tax
Exemption – Commercial Motor Vehicles or Trailers Greater than 54,000 Pounds
(Form
5435), to apply for an exemption from sales tax.
Purchaser’s (Lessor’s) Name
Purchase Date (MM/DD/YYYY)
Purchaser’s (Lessor’s) Telephone Number
__ __ /__ __ /__ __ __ __
(__ __ __) __ __ __ - __ __ __ __
Doing Business As
Lessee’s Name, if applicable
Lease Date if applicable (MM/DD/YYYY)
__ __ /__ __ /__ __ __ __
Purchaser’s (Lessor’s) Address
Lessee’s Address, if applicable
1. The purchaser is registered (or has a lease agreement with someone who is registered) as a common carrier to provide “for hire” services in
(select one):
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Interstate commerce and is registered with the Federal Motor Carrier Safety Administration (FMCSA).
Please provide: United States Department of Transportation (USDOT) registration number, if applicable: __________________________ .
FMCSA operating authority (MC) number: ___________________________________________________________________________ .
r
Interstate commerce hauling exempt commodities and has filed the carrier’s information with the FMCSA Safety and Fitness Electronic
Records (SAFER) System. Please provide your USDOT registration number: _______________________________________________ .
r
Intrastate commerce and is registered with the Missouri Division of Motor Carrier Services.
Please provide your USDOT registration number: _____________________________________________________________________ .
2. The purchaser certifies the following regarding all vehicle(s) or trailer(s) listed below.
• The purchaser (or individual named in the lease agreement) holds itself out to the public as engaging in “for hire” transportation of
exempt commodities, passengers, or property of others. Please explain how the purchaser (or individual named in the lease
agreement) holds itself out for hire to the public. __ ____________________________________________________________________
• The purchaser (or individual named in the lease agreement) will use the motor vehicle(s) or trailer(s) for the purpose noted herein.
• If a lease agreement is involved, the lease is for at least 30 days.
• Each motor vehicle will be:
- Registered for, and capable of hauling or carrying, at least 24,000 lbs. or more including vehicle weight; or
- Registered as a commercial bus and capable of carrying eight or more passengers.
• If registering at a later date, provide the licensed gross weight to be applied for and the state of licensure for each motor vehicle or trailer.
Vehicle Identification Number (VIN)
Purchase or Lease Date (MM/DD/YYYY)
__ __ /__ __ /__ __ __ __
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Year
Make
Model
Licensed Gross Weight
State of Licensure
__ __ __ __
Vehicle Identification Number (VIN)
Purchase or Lease Date (MM/DD/YYYY)
__ __ /__ __ /__ __ __ __
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Year
Make
Model
Licensed Gross Weight
State of Licensure
__ __ __ __
Vehicle Identification Number (VIN)
Purchase or Lease Date (MM/DD/YYYY)
__ __ /__ __ /__ __ __ __
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Year
Make
Model
Licensed Gross Weight
State of Licensure
__ __ __ __
Vehicle Identification Number (VIN)
Purchase or Lease Date (MM/DD/YYYY)
__ __ /__ __ /__ __ __ __
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Year
Make
Model
Licensed Gross Weight
State of Licensure
__ __ __ __
Under penalties of perjury, I declare that the information I have provided an any attached supplement is true, correct, and complete.
Purchaser’s (or Authorized Agent) Signature
Typed or Printed Name
Date Signed (MM/DD/YYYY)
__ __ /__ __ /__ __ __ __
Form 5095 (Revised 08-2013)
Mail to:
Motor Vehicle Bureau
Phone: (573) 526-3669
P.O. Box 100
dor.mo.gov/pdf/commoncarriers.pdf
Visit
E-mail:
mvbmail@dor.mo.gov
Jefferson City, MO 65105-0100
for additional information.
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