Affidavit in Support of a Claim for
Exemption from Sales or Use Tax for Transfer
of a Fire Engine or Ambulance
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
Motor Vehicle Transferred:
Vehicle identification number
, an authorized representative of
Name of organization
certify that it is a volunteer non-profit organization providing
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.
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
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 certain fire trucks and
ambulances is provided for by the Massachusetts regulations
If you have any questions about the acceptance or use of this
and statutes. In order to be exempt from the sales or use tax you
affidavit, please contact:
must meet the requirements of the law and complete the affidavit
Massachusetts Department of Revenue
above. You must fill in all blanks and print your entries, except at
Customer Service Bureau
the end of the affidavit where your signature is required.
PO Box 7010
Boston, MA 02204
This form is approved by the Commissioner of Revenue and may be reproduced.