Arizona Affidavit of Nonresidency by a Resident of Another U.S. State Purchase of Motor Vehicle in Arizona

Affidavit of Nonresidency by a Resident of Another U.S. State Purchase of Motor Vehicle in Arizona
Arizona Form 5011
ARIZONA FORM

Arizona Department of Revenue

5011

CERTIFICATE TO ESTABLISH RESIDENCY IN ANOTHER
U.S. STATE PURSUANT TO A.R.S. § 42-5009

FOR PURPOSE OF A STATUTORY DEDUCTION PROVIDED BY ARS § 42-5061, SUBSECTION (A)(14)(a)-(b), (A)(28)(a), (A)(44), OR (U)

SECTION 1 - INFORMATION TO BE SUPPLIED BY SELLER

Section 1 only is fillable.

SELLER’S NAME AND ADDRESS:
YEAR:

MAKE:

SALES PRICE:

$

MODEL:

VIN NO.:

90 DAY PERMIT NO.:

PRICE ADJUSTMENTS:

NET PRICE:

TOTAL TAXES PAID:

$

DRIVER’S LICENSE NO. OF PURCHASER (or Entity Rep.):

$

$

STATE OF ISSUANCE:

EXPIRES:

IF CLAIMING THE COMMERCIAL MOTOR VEHICLE USED IN INTERSTATE COMMERCE SOLD TO NONRESIDENT EXEMPTION, THE
SELLER MUST FILL OUT THE FOLLOWING INFORMATION ABOUT THE PURCHASER:
USDOT # __________________ | MC/MX/FF #(s) ____________________ | INTERSTATE
INTERSTATE C
COMMERCE
OMMERCE:: Y____ N____ | GVWR _____________
Note: To be eligible, vehicle must be operated in interstate commerce and have a gross vehicle weight rating (GVWR) over 10,000 pounds.

You may now print your form; click the red print button.

SECTION 2 - TO BE COMPLETED BY PURCHASER (OR ENTITY REPRESENTATIVE)
FULL NAME:

FULL RESIDENTIAL ADDRESS (NO P.O. BOXES):
TELEPHONE NO. OF RESIDENCE ADDRESS:

AUTO INSURANCE COMPANY:

POLICY NO.:

IF PURCHASER IS A NONRESIDENT ENTITY, COMPLETE THE FOLLOWING:

FEIN:

FULL BUSINESS ADDRESS:

TELEPHONE NO.:

ENTITY NAME:

QUESTIONS TO BE ANSWERED AND INITIALED BY PURCHASER (OR ENTITY REP.):
	
	
	
	

NOTE:	 DO NOT answer questions 1, 2, and 3 if you are a Nonresident U.S. Military Service member (or spouse) officially

stationed at an Arizona military facility, a Nonresident Student enrolled at an Arizona Educational Institution paying out-of-state
tuition fees (PROVIDE COPY OF MILITARY ORDERS OR CURRENT STUDENT I.D. CARD), or a nonresident working
in Arizona but who lives outside of Arizona within 25 miles of the border.

		

True	 False	 Initial

	 1.	 I am physically present in Arizona for at least seven (7) months of the year.................................................... 	 

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	 4.	 I attend an Arizona educational institution and pay resident status tuition rates.............................................. 	 

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	5.	I am an individual or entity that maintains a main office, branch office or warehouse facilities in this
state and that bases and operates motor vehicles in this state........................................................................ 	 

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	2.	I am engaged in a trade, profession or occupation in Arizona in other than seasonal
agricultural work or temporary seasonal work.................................................................................................. 	 
	 3.	 I am employed in the State of Arizona.............................................................................................................. 	 

	6.	I am an individual or entity that operates motor vehicles in transportation services within Arizona, for
other than seasonal agricultural work............................................................................................................... 	 
	7.	I am purchasing this vehicle for transfer to a resident of Arizona..................................................................... 	 
	 8.	 I have a valid driver’s license issued by the State of Arizona........................................................................... 	 
	 9.	 I am registered to vote in the State of Arizona................................................................................................. 	 
	10.	 I file Resident status income tax returns, or business tax returns in the State of Arizona................................ 	 
	11.	 The insurance policy listed above (other than a temporary binder) is issued under the laws of Arizona......... 	 

NOTE: FOR SECTION 2, AN ARIZONA ADDRESS OR ANY TRUE ANSWER RENDERS THE PURCHASER INELIGIBLE.
ADOR 10739 (3/23)

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AFFIDAVIT OF NONRESIDENCY

AFFIRMATIONS OF PURCHASER:
I will register this vehicle in the state of 	
prior to the expiration of the 90 Day
	
Nonresident Registration Permit, and will not use this vehicle in Arizona after this date for other
	
than purely temporary or transitory purposes.
I will personally be liable for an amount equal to the state, county and city taxes that would have
	
applied to a non-exempt sale, plus penalties and interest computed from the date of sale, if this
	
vehicle is registered in Arizona within 365 days of the date of sale.
I will personally be liable for an amount equal to the state, county and city taxes that would have
	
applied to a non-exempt sale, plus penalties and interest computed from the date of sale, if I
	
have provided false information on this certificate.
I understand that in Arizona, it is a Class 5 Felony to “knowingly prepare, present or aid, procure or
	
advise in preparing or presenting any return, affidavit, claim or other document which is fraudulent
	
or is false as to any material matter, whether or not the falsity or fraud is with the knowledge
	
or consent of the taxpayer authorized or required to present the return, affidavit, claim or
	
document.” [See A.R.S. § 42-1127(B)(2)]
I understand that I will be subject to criminal penalties if I have either omitted required information or
	
provided false information on this certificate. [See A.R.S. § 42-1127(B)(4)]
If
	
	

claiming the commercial motor vehicle sold to a nonresident exemption under
A.R.S. § 42-5061(A)(14)(b), I verify that I am authorized to use the vehicle in interstate
commerce as defined in 49 U.S.C. § 13501.

I have verified that my driver’s license information provided on Page 1 is correct.
I hereby certify that the information I have provided on this Certificate is true, accurate and
complete. Further, if I am the representative of a nonresident entity, I certify that I am
authorized to execute this Certificate on behalf of the nonresident entity named above.

Signed by:
	
	
Purchaser or Entity Representative		

ADOR 10739 (3/23)

	
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