Arizona Certificate For Sale And Delivery Of Motor Vehicle To Nonresident For Use Outside Of Arizona

Certificate For Sale And Delivery Of Motor Vehicle To Nonresident For Use Outside Of Arizona
Arizona Form 5010
ARIZONA DEPARTMENT OF REVENUE

ARIZONA FORM

5010

CERTIFICATE TO ESTABLISH OUT-OF-STATE DELIVERY
OF MOTOR VEHICLE TO NONRESIDENT

FOR PURPOSE OF THE STATUTORY DEDUCTIONS PROVIDED BY A.R.S. §§ 42-5061(A)(14) AND 42-6004 (A)(4)

This certificate 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 Certification on page 2 is not required, and
the seller’s signature may be witnessed by an Arizona notary public.
SELLER INFORMATION:

This section is fillable.

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

, 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)

NOTARY SEAL

PURCHASER INFORMATION:

This section is fillable.

PURCHASER’S NAME (PLEASE PRINT):

STATE:

DRIVER’S LICENSE NO.:

ADDRESS:
CITY STATE ZIP:

PURCHASER CERTIFICATION:

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I certify, under penalty of perjury under the laws of the State of Arizona, that I personally accepted
delivery of the above vehicle at the delivery address indicated on page 1, and that this vehicle is
purchased for use outside of Arizona.

SIGNATURE OF PURCHASER OR REPRESENTATIVE

DATE OF DELIVERY

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NOTARY STATEMENT
State of
County of
On this

day of

, 20

, before me personally appeared

, whose identity was proved to me on the

NOTARY SEAL

(PURCHASER OR REPRESENTATIVE)

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:

SELLER:
Remit a copy of this form, and all other executed Form 5010’s, to the Arizona Department
of Revenue on a quarterly basis. Attach the associated Form 5011 or Form 5012 to each Form 5010
submitted. (See TPP 08-1 and Form 5010Q).
Mail to:

NONRESIDENT MOTOR VEHICLE PROGRAM - TPT AUDIT DIVISION
ARIZONA DEPARTMENT OF REVENUE
1600 W. MONROE, ROOM 620
PHOENIX, AZ 85007

ADOR 60-5385f (9/08)