2019 Affidavit
Knox County Clerk
Post Office Box 1566 Knoxville, TN 37901 (865)215-2385 www.knoxcounty.org/clerk
Affidavit for Whee
l Tax Exemption
Motor Vehicle Division Pursuant to Knox County Charter Section 58-1 & T.C.A. § 5-8-102
Please complete this affidavit, in its entirety, and return it with registration or tag renewal.
Registered Owner Information:
Name: _______________________________________________________________ Date of Birth: ____________________
(Print exactly as shown on title/registration)
Address: ________________________________________ City: ________________________ Zip: ____________________
Phone: ____________________
Vehicle Information:
Make: __________Year: __________ Model: __________ Current Plate #: ____________________
Basis for Exemption: (Check one)
Registered owner/owners who is 65 years old or older AND has a combined annual income equal to or less than
$16,430.00 per year. $30.00 EXEMPTION
Documentation required: Driver’s License or birth certificate, AND one (1) of the following for which you qualify:
Income Tax Return (1040A form)
OR Social Security Statement from 2017 (if 1040A income tax form was not filed)
Registered owner/owners who has been certified as totally disabled by the Social Security
Administration or the U.S. Dept. of Veteran’s Affairs AND has a combined annual income equal to
or less than $16,430.00 per year. $30.00 EXEMPTION
Documentation required: Driver’s License or birth certificate AND one (1) of the following for which
you qualify: Award of SSI (supplemental security income)
Award of SSD (social security disability)
Award of Disabled VA
Registered owner/owners of the vehicle who are active duty members of the United States Army, Navy, Marine
Corps, Air Force, and Coast Guard
OR members of the Army Reserve, Naval Reserve, Marine Corps Reserve,
Air Force Reserve, Coast Guard Reserve, Army National Guard and Air National Guard who are called to full-
time active duty service. $36.00 EXEMPTION
Documentation required
: Copy of Stationing Orders (must reflect full-time active duty status for reserve/national guard members)
Registered owner is a veteran who has a 100% permanent total disability from a service-connected cause OR
is a former prisoner of war, as determined by the U.S. Dept. of Veterans Affairs. $36.00 EXEMPTION
Documentation required:
DD214 Certificate or other appropriate VA related forms
School bus under contract with Knox County Board of Education. $36.00 EXEMPTION
Documentation required: Certification from Knox County Schools
I certify that the foregoing statements are
true and correct to the best of my knowledge and understanding. I
further acknowledge that if the basis for my exemption is in part due to limited income that I have disclosed and
attached hereto any and all sources of income for myself and any other owner of such motor vehicle.
______________________________________________ _______________ _______________________________________
Signature of Applicant Date Clerk Signature
Revised 12/19/2013
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