Arizona Form 5013 - Certificate To Establish Native American Status And Residence On Arizona Reservation
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1Arizona Department of Revenue
ARIZONA FORM
5013
C
E
N
A
S
ERTIFICATE TO
STABLISH
ATIVE
MERICAN
TATUS
R
A
R
AND
ESIDENCE ON
RIZONA
ESERVATION
FOR PURPOSE OF THE STATUTORY DEDUCTION PROVIDED BY ARS § 42-5061(A)(28)(b)
S
M
V
N
A
R
R
ALE OF
OTOR
EHICLE TO
ATIVE
MERICAN
ESIDING ON
ESERVATION: A.R.S. § 42-5061(A)(28)(b)
provides an exemption from state transaction privilege tax for income derived from the sale of a motor vehicle
to “[a]n enrolled member of an Indian tribe who resides on the Indian reservation established for that tribe.”
This exemption does not apply to city privilege tax.
NATIVE AMERICAN PURCHASER:
ENROLLED MEMBER NAME:
DRIVER’S LICENSE NO.:
ADDRESS ON RESERVATION (FROM DRIVER’S LICENSE):
TRIBAL ID CARD NO.:
CITY STATE ZIP:
NAME OF TRIBE:
*
CO - PURCHASER:
ENROLLED MEMBER NAME:
DRIVER’S LICENSE NO.:
ADDRESS ON RESERVATION (FROM DRIVER’S LICENSE):
TRIBAL ID CARD NO.:
CITY STATE ZIP:
NAME OF TRIBE:
*
NOTE: If the Co-Purchaser of this vehicle is not a Native American residing on an Arizona reservation established for his
or her tribe, the deduction amount shall be limited to 50% of the net sales price of the vehicle.
A seller that has reason to believe that the certifi cate is not accurate, complete or applicable to the transaction, may
A seller that has reason to believe that the certifi cate is not accurate, complete or applicable to the transaction, may
not accept the certifi cate in good faith and the seller will not be relieved of the burden of proving entitlement to the
not accept the certifi cate in good faith and the seller will not be relieved of the burden of proving entitlement to the
exemption. A seller that accepts a certifi cate in good faith will be relieved of the burden of proof and the purchaser
exemption. A seller that accepts a certifi cate in good faith will be relieved of the burden of proof and the purchaser
may be required to establish the accuracy of the claimed exemption. If the purchaser cannot establish the accuracy
may be required to establish the accuracy of the claimed exemption. If the purchaser cannot establish the accuracy
and completeness of the information provided in the certifi cate, the purchaser is liable for an amount equal to the
and completeness of the information provided in the certifi cate, the purchaser is liable for an amount equal to the
transaction privilege tax, penalty and interest which the seller would have been required to pay if the seller had
transaction privilege tax, penalty and interest which the seller would have been required to pay if the seller had
not accepted the certifi cate. Misuse of this certifi cate will subject the purchaser to payment of the ARS § 42-5009
not accepted the certifi cate. Misuse of this certifi cate will subject the purchaser to payment of the ARS § 42-5009
amount equal to any tax, penalty or interest. Willful misuse of this certifi cate will subject the purchaser to criminal
amount equal to any tax, penalty or interest. Willful misuse of this certifi cate will subject the purchaser to criminal
penalties of a felony pursuant to ARS § 42-1127(B)(2).
penalties of a felony pursuant to ARS § 42-1127(B)(2).
Certifi cation
Certifi cation
I, (print full name)
I, (print full name)
, hereby certify that I am a Native
, hereby certify that I am a Native
American and that I reside on the reservation established for my tribe, and that the information on
American and that I reside on the reservation established for my tribe, and that the information on
this certifi cate is true, accurate and complete.
this certifi cate is true, accurate and complete.
Signature of purchaser
Signature of purchaser
Date
Date
I, (print full name)
I, (print full name)
, hereby certify that I am (am not) a
, hereby certify that I am (am not) a
Native American and that I do (do not) reside on the reservation established for my tribe, and that the
Native American and that I do (do not) reside on the reservation established for my tribe, and that the
information on this certifi cate is true, accurate and complete.
information on this certifi cate is true, accurate and complete.
Signature of co-purchaser
Signature of co-purchaser
Date
Date
Exact reproductions and photocopies of this exemption certifi cate are acceptable for use.
ADOR 60-5606 (9/08)
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