Form Mvu-23 - Affidavit In Support Of A Claim For Exemption From Sales Or Use Tax For A Motor Vehicle, Trailer Or Other Vehicle Transferred To An Insurer

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Form MVU-23
Rev. 4/99
Affidavit in Support of a Claim for Exemption
Massachusetts
from Sales or Use Tax for a Motor Vehicle,
Department of
Trailer or Other Vehicle Transferred to an Insurer
Revenue
Please read the instructions below before completing this form and provide the following information.
All entries must be printed or typed except for signature.
This claim for exemption is based on a transfer to an insurer by an insured in connection with a claim for the loss or loss of use of the vehicle under an
insurance policy.
Motor Vehicle Transferred:
Year
Make
Model
Vehicle identification number
Title number
I,
, an authorized representative of
Name
Name of insurer
certify that the above-described vehicle was transferred by
Address
City/Town
State
Zip
an insured in connection with a claim under an insurance contract for the loss or loss of use of the vehicle.
Declaration
I declare under the pains and penalties of perjury that I have reviewed this affidavit and the statements I have made in it and declare that they
are true.
Authorized representative
Date
Instructions
The purchaser of a motor vehicle acquired for use, storage or
Please note that your statements are to be made under the pains
other consumption in the Commonwealth of Massachusetts is
and penalties of perjury and that a statement which is made will-
required to pay a sales or use tax unless an exemption is specifi-
fully and is false as to a material matter may be punished as a
cally provided for in the Massachusetts General Laws or the
felony under Massachusetts General Laws, Chapter 62C, sec-
Code of Massachusetts Regulations.
tion 73, or Chapter 268, section 1A. Perjury is a serious crime
and punishment can be severe.
An exemption from the sales or use tax for transfers by an in-
sured in connection with a claim under an insurance contract for
If you have any questions about the acceptance or use of this
the loss or loss of use of the vehicle is provided for by the Mass-
affidavit, please contact:
achusetts regulations and statutes. In order to be exempt from
Massachusetts Department of Revenue
the sales or use tax you must meet the requirements of the law
Customer Service Bureau
and complete the affidavit above. You must fill in all blanks and
PO Box 7010
print your entries, except at the end of the affidavit where your
Boston, MA 02204
signature is required.
(617) 887-MDOR
This form is approved by the Commissioner of Revenue and may be reproduced.

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