Fillable Printable Form Muv-23

Form Muv-23

The purchaser of a motor vehicle acquired for use, storage or

other consumption in the Commonwealth of Massachusetts is

required to pay a sales or use tax unless an exemption is specifi-

cally provided for in the Massachusetts General Laws or the

Code of Massachusetts Regulations.

An exemption from the sales or use tax for transfers by an in-

sured in connection with a claim under an insurance contract for

the loss or loss of use of the vehicle is provided for by the Mass-

achusetts regulations and statutes. In order to be exempt from

the sales or use tax you must meet the requirements of the law

and complete the affidavit above. You must fill in all blanks and

print your entries, except at the end of the affidavit where your

signature is required.

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

Rev. 4/99

Massachusetts

Department of

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:

YearMakeModelVehicle identification numberTitle number

I, , an authorized representative of

certify that the above-described vehicle was transferred by

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 representativeDate

Instructions

Please note that your statements are to be made under the pains

and penalties of perjury and that a statement which is made will-

fully and is false as to a material matter may be punished as a

felony under Massachusetts General Laws, Chapter 62C, sec-

tion 73, or Chapter 268, section 1A. Perjury is a serious crime

and punishment can be severe.

If you have any questions about the acceptance or use of this

affidavit, please contact:

Massachusetts Department of Revenue

Customer Service Bureau

PO Box 7010

Boston, MA 02204

(617) 887-MDOR

This form is approved by the Commissioner of Revenue and may be reproduced.

Name of insurerName

AddressCity/TownStateZip