State Tax Form 126A-MVE
The Commonwealth of Massachusetts
Assessors’ Use only
Revised 12/2004
Date Received
Name of City or Town
Application No.
CALENDAR YEAR __________________
MOTOR VEHICLE EXCISE EXEMPTION APPLICATION
MANUFACTURERS-FARMERS
General Laws Chapter 60A §1
Return to: Board of Assessors
Must be received by the assessors within three
years after the excise is due, or one year after the
excise is paid, whichever is later.
INSTRUCTIONS: Please print or type.
A. TAXPAYER INFORMATION.
Name(s) Telephone No. ( )
Address (Business)
N
o. Street City/Town Zip Code
Manufacturer/Farmer Plate Number
B. VEHICLES. List all vehicles being operated exclusively for business purposes with the plate during calendar year.
Year Make Model VIN Use
Continue list on attachment, in same format, as necessary.
C. SIGNATURE. I certify that every vehicle listed in this application is or will be operated solely for business purposes
and no vehicle exempted from the excise is or will be operated in any way for my personal use or convenience, or
that of a family member or any other person. Any personal use of a vehicle subjects it to the excise and a penalty of
$100.
Subscribed under the penalties of perjury
Signature of applicant
Date
DISPOSITION OF APPLICATION (ASSESSORS’ USE ONLY)
GRANTED
Board of Assessors
DENIED
Date
THIS FORM APPROVED BY THE COMMISSIONER OF REVENUE
