Form 5010 - Certificate To Establish Out-Of-State Delivery Of Motor Vehicle To Nonresident - Arizona Department Of Revenue

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ARIZONA DEPARTMENT OF REVENUE
ARIZONA FORM
5010
C
E
O
O
S
D
ERTIFICATE TO
STABLISH
UT-
F-
TATE
ELIVERY
M
V
N
OF
OTOR
EHICLE TO
ONRESIDENT
FOR PURPOSE OF THE STATUTORY DEDUCTIONS PROVIDED BY A.R.S. §§ 42-5061(A)(14) AND 42-6004 (A)(4)
This certifi cate is required to document the seller’s out-of-state delivery of a motor vehicle to a
nonresident purchaser, for purposes of the above exemptions from state transaction privilege tax and city
privilege tax. If delivery is made by the seller or the seller’s agent, this form must be fully completed and
notarized in the state of delivery, and records of any expenses incurred in delivering the motor vehicle must
be maintained by the seller. If the seller contracts with a licensed auto transporter or common carrier
for the out-of-state delivery of the vehicle, the Purchaser Certifi cation on page 2 is not required, and
the seller’s signature may be witnessed by an Arizona notary public.
This section is fillable.
SELLER INFORMATION:
SELLER’S NAME:
TPT LICENSE NO.:
ADDRESS:
PHONE NO.:
(
)
CITY STATE ZIP:
VEHICLE INFORMATION:
This section is fillable.
YEAR / MAKE / MODEL:
VIN NO.:
NET SALES PRICE:
ADOT 90 DAY PERMIT NO.:
$
DELIVERY OF VEHICLE:
This section is fillable.
DELIVERY ADDRESS:
CITY STATE ZIP:
NAME OF PERSON DELIVERING VEHICLE:
JOB TITLE:
PHONE NO.:
(
)
SELLER CERTIFICATION (check one box):
Please complete the Purchase Information on page 2 before printing the form.
I certify, under penalty of perjury under the laws of the State of Arizona, that I personally delivered
the above vehicle to the delivery address indicated above.
I certify, under penalty of perjury under the laws of the State of Arizona, that I have delivered the
above vehicle to a licensed auto transporter or common carrier who will deliver the vehicle to the
above address and from whom I have received a bill of lading. (See Notice above.)
SIGNATURE OF SELLER OR PERSON DELIVERING VEHICLE
DATE OF DELIVERY
NOTARY STATEMENT
State of
County of
On this
day of
, 20
, before me personally appeared
NOTARY SEAL
, whose identity was proved to me on the
(SELLER OR PERSON DELIVERING VEHICLE)
basis of satisfactory evidence to be the person whose name is subscribed to this
document and who acknowledged that he/she signed the above document.
Notary Signature:
ADOR 60-5385f (9/08)

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