(CAG & GD) Sierra Auction - Arizona - Non-resident of Arizona based in U.S.A. (Form 5011)

Only complete this form if you meet the all of the following criteria:

1. You are based in the United States of America

2. You reside in a state outside of Arizona

3. You are seeking sales tax exemption for a vehicle that was purchased within the state of Arizona from the seller "Sierra Auction."

Are you either a Nonresident U.S. Military Service member officially stationed at an Arizona military facility, or a Nonresident of Arizona who is a student that is enrolled at an Arizona Educational Institution that is paying out-of-state tuition fees?

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

TRUEFALSE

2. I am engage in a trade, profession or occupation in Arizona in other than seasonal agricultural work or temporary seasonal work:

TRUEFALSE

3. I am employed in the State of Arizona:

TRUEFALSE

4. I have placed my children in an Arizona public school (K-12) without payment of nonresident tuition:

TRUEFALSE

5. I attend an Arizona educational institution and pay resident status tuition rates:

TRUEFALSE

6. I am an individual, partnership, company, firm, corporation or association that maintains a main office, a branch office or warehouse facilities in Arizona and operates a motor vehicle in Arizona:

TRUEFALSE

7. I am an individual, partnership, company, firm, corporation or association that operates a motor vehicle in intrastate transportation, for other than seasonal agricultural work:

TRUEFALSE

8. I am purchasing this vehicle for transfer to a resident of Arizona:

TRUEFALSE

9. I have a valid driver's license issued by the State of Arizona:

TRUEFALSE

10. I am registered to vote in the State of Arizona:

TRUEFALSE

11. I file Resident status income tax returns, or business tax returns in the State of Arizona:

TRUEFALSE

12. My auto insurance policy is issued under the laws of Arizona (other than temporary 90-day license from Arizona Motor Vehicle Division):

TRUEFALSE

You are ineligible for sales tax exemption.

The sales tax must be paid directly to Liquidity Services.

Please provide a current, valid copy of your driver's license, indicating an address outside of Arizona:

Please provide a copy of your current student identification card or military orders (whichever applies):

Driver's License Number:

State that issued your driver's license:

Expiration date of your driver's license:

What documentation are you providing to prove that the asset is leaving Arizona?

(90 day) What is the permit number?

Please provide a copy of the 90-day permit

Please provide a copy of the Bill of Lading (BOL):

Your Account Username:

Note: This is what you use to sign into govdeals.com and/or allsurplus.com. This is NOT your first name and last name.

Your Full Name:

Your initials

Initials for 1 and 2 and 3 (if applicable)

Your Residential Address (NO P.O. Boxes):

Street Address

Street Address Line 2

CityState

Zip Code

Your Auto Insurance Company:

Your Auto Insurance Policy Number:

Your Email:

Do you own a company?

Your Company's Name:

Your Company's Address:

Street Address

Street Address Line 2

CityState

Zip Code

Your Company's Federal Employer ID Number (FEIN):

Your Phone Number:

Format: (000) 000-0000.

(Business) Phone Number:

Format: (000) 000-0000.

The LOT # that you are seeking tax exemption for:

Example: 25917-1 is 25917-001

Winning bid amount:

Year:

Make:

Model:

VIN:

Which state are you registering this vehicle in prior to the expiration of the 90-day Non-resident Registration permit?

Your affirmations:

I will register this vehicle in the state listed above prior to the expiration of the 90 Day Nonresident Registration Permit (if applicable), 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 ordocument.” [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)

Signature

Date:

Date

Seller name and address