Free 41806.pdf - Indiana

AFFIDAVIT OF GROSS RETAIL AND USE TAX
State Form 41806 (R2 / 5-97) / BMV Form 15ST

INDIANA DEPARTMENT OF REVENUE

AFFIDAVIT OF GROSS RETAIL AND USE TAX
State Form 41806 (R2 / 5-97) / BMV Form 15ST

INDIANA DEPARTMENT OF REVENUE

Name of seller

Name of seller

Address of seller (number and street or Rural Route)

Address of seller (number and street or Rural Route)

City

State

ZIP code

City

State

ZIP code

Name of purchaser

Name of purchaser

Date of sale (month, day, year)

Date of sale (month, day, year)

Vehicle / Watercraft year

Body type

Vehicle / Watercraft make

Vehicle / Watercraft year

Body type

Vehicle / Watercraft make

Model number

Identification number

Model number

Identification number

Selling price of vehicle / watercraft

Year of trade-in

Selling price of vehicle / watercraft

Year of trade-in

$
Value of trade-in vehicle / watercraft Make of trade-in

$
Value of trade-in vehicle / watercraft Make of trade-in

$
Total price paid Type of trade-in Total price paid

$
Type of trade-in

$

$

I hereby verify under the penalty of perjury that the total price paid for the above described vehicle / watercraft represents the true amount collected for the sale of the vehicle / watercraft. This statement is made for the purpose of providing a value for use by the Indiana Department of Revenue in determining the purchaser's sales (use) tax.
Signature of seller Date (month, day, year)

I hereby verify under the penalty of perjury that the total price paid for the above described vehicle / watercraft represents the true amount collected for the sale of the vehicle / watercraft. This statement is made for the purpose of providing a value for use by the Indiana Department of Revenue in determining the purchaser's sales (use) tax.
Signature of seller Date (month, day, year)