Fillable Printable Form Mvu-21

Form Mvu-21

Under Massachusetts law, all purchasers of motor vehicles ac-

quired for use, storage or consumption in Massachusetts are re-

quired to pay a sales or use tax unless a specific exemption is pro-

vided. However, any person to whom a motor vehicle title is trans-

ferred as a result of a contest, drawing or raffle may be exempt

from the sales or use tax. To qualify for this exemption, you must

meet all the requirements of the law and complete this affidavit.

Form MVU-21

Affidavit in Support of a Claim for Exemption

from Sales or Use Tax for a Motor Vehicle

Transferred by Contest, Drawing or Raffle

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 signatures.

This claim for exemption is based on a transfer of a motor vehicle without consideration as a result of winning a contest, drawing or raffle.

W arning: W illful misuse of this affidavit is punishable as a felony under Massachusetts General Laws, Chapter 62C, section 73 or Chapter 268,

section 1A.

Motor Vehicle Transferred:

Year Make Model Vehicle identification number Title number

Name of donor (dealer)

Address City/Town State Zip

Name of sponsor

Address City/Town State Zip

Name of contest/drawing/raffle winner

Address City/Town State Zip

Sales/use tax has been paid by (name of sponsor or donor)

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.

Winner’s signature Date

Sponsor’s signature Date

Instructions

To be valid, all items on Form MVU-21 must be completed. Please

print or type all items except signatures. 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.