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Form Mvu-22 - Affidavit In Support Of A Claim For Exemption From Sales Or Use Tax For Transfer Of A Fire Engine Or Ambulance

Form MVU-22

Rev. 4/99

Affidavit in Support of a Claim for

Massachusetts

Exemption from Sales or Use Tax for Transfer

Department of

of a Fire Engine or Ambulance

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 the transfer of a fire engine or ambulance to a volunteer non-profit organization providing public fire protection or

ambulance service.

Motor Vehicle Transferred:

(check one)

Fire engine

Ambulance

Year

Make

Model

Vehicle identification number

Title number

, an authorized representative of

Name

Name of organization

certify that it is a volunteer non-profit organization providing

Address

City/Town

State

Zip

public fire protection or public ambulance service. The above-described motor vehicle was purchased or transferred exclusively for use as a fire engine

or ambulance by the organization.

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-