Phone No Street Address Phone NoSocial Security No or Federal ID NoCityCountyStateZIP CodeVehicle Identi31cation NumberYearMakeYearMake Title NumberTradein AllowanceBuyer146s SignatureSell ID: 886048
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1 71A100 (04-16)Commonwealth of KentuckyDE
71A100 (04-16)Commonwealth of KentuckyDEPARTMENT OF REVENUEAFFIDAVIT OF TOTAL CONSIDERATIONGIVEN FOR A MOTOR VEHICLE Phone No. Street Address Phone No. Social Security No. or Federal ID No.CityCountyStateZIP Code Vehicle Identi cation NumberYearMakeYearMake Title NumberTrade-in AllowanceBuyer’s SignatureSeller’s SignatureTitleSubscribed and sworn to before me this ______day of _____________ 20____ My commission expires Title Giving a false statement as to the total consideration paid is a Class D Felony with a minimum ne of $2,000 per KRS 190.990(5).We declare and af rm under penalty of law that the information given herein to the best of our knowledge and belief represents the “total consideration given” in exchange for the vehicle and “trade-in allowance” granted for any vehicle traded in.If this af davit is incomplete, tax will be based on the MSRP of a new vehicle or the retail value from the prescribed reference manual for a used vehicle. Buyer(s) will be liable for any additional tax, plus applicable penalty and interest. Subscribed and sworn to before me this ______day of _____________ 20____ My commission expiresLess Trade-in Allowance Total Consideration Given* Less Trade-in Allowance Total Consideration Given*