Vehicle Services Bureau
Sponsor Orgnization's
Expenditure
Statement of Fact
Only
Statement detailing additional information from expenditures
Under penalty of law (MCA 45-7-203), I certify that the statements made and information contained on this form are
true and correct to the best of my knowledge, information, and belief; I am the person named on this form; and, if
signing for a business entity or trust, I have full authority to do so.
Signature _____________________________________________________________________ Date ________________________
This is my legal signature
Printed name _______________________________________________________________________________________________
Montana county and state authorities reserve the right to reject any form that has been altered.
MV117A (2/20)
This form is available in alternate formats for people with disabilities.
P.O. Box 201431, 302 N Roberts, Helena, MT 59620-1431
Phone (406) 444-3661 Fax (406) 444-0116 mvdtitleinfo@mt.gov
Email Address ______________________________________________ Phone Number ___________________________________
Expenditures
Amount:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Total Expenditures in Montana from specialty plate fees
$
$
Total collected from generic specialty plate fees
Expenditures in Montana from specialty plate fees
Description:
$
$
$
$
$
$
$
$
$
$
