ASSESSMENT DIVISION
125 MAIN STREET
EAST GREENWICH, RI 02818
AFFIDAVIT
OF VEHICLE OPERATED EXCLUSIVELY IN INTERSTATE COMMERCE
DATE FILED___________
NAME OF
COMPANY______________________________________________
ADDRESS__________________________________________________________
__________________________________________________________
We, the undersigned, hereby certify that we are an express
company that transports goods or passengers for hire and the vehicle herein
described will be:
Used exclusively in interstate operations under ICC Permit
#___________________________
Traveling
routes__________________________________________________________________________________________
______________________________________________________________________________________________________
Engaged in hauling the
following__________________________________________________________________________
__________________________________________________,
exclusively in the conduct of interstate traveling routes:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
DESCRIPTION OF VEHICLE
____________________________________________________________________________________________
YEAR
MAKE MODEL PLATE # V.I.N.
I swear that the vehicle listed above is exempt from
excise tax on the basis that such vehicle will be used as reported above. Any other use may subject the vehicle to
excise tax.
Signed under penalty of perjury on this day of
_____________________________________,20__
____________________________________________________________________________________________
NAME OF REGISTRANT
TITLE