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 the transfer of a motor
vehicle by repossession is provided for by the Massachusetts
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
Affidavit in Support of a Claim for Exemption
from Sales or Use Tax for a Motor Vehicle
Transferred by Repossession
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 of a motor vehicle by repossession.
Motor Vehicle Transferred:
Year Make Model Vehicle identification number Title number
I, , an authorized representative of
certify that the above-described vehicle was repossessed
under the authority of a lien or security interest.
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
Authorized representative Date
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
This form is approved by the Commissioner of Revenue and may be reproduced.
Address City/Town State Zip
Name of lienholder or security holder