Form 62A044 – Fill Out and Use This PDF

Owner _____________________________________________________ Telephone No. ( ____ ) ___________________

Address ________________________________________ State ________ ZIP Code _________________________

License Plate/KY No. _________________________________ VIN/HIN ________________________________________

Year ___________________________ Make _________________________ Model _____________________________

Vehicle was sold in state prior to January 1, ______ to: _____________________________________________

Date sold _________________________ (Code S) City Sold _________________________________________

Vehicle was sold out-of-state prior to January 1, ______ to: ___________________________________________

Date sold _________________________	(Code S) City, State Sold ___________________________________
 Vehicle was in junkyard prior to January 1,	at: ____________________________________________________
Date junked _______________________*	(Code J)

Vehicle wrecked and settled with insurance company prior to January 1, ______.

Settlement date ____________________ (Code J)

*I understand that if this vehicle/boat has been junked and the tag and title have not been returnedto the county clerk’s office and I do not have these items in mypossessionthatImust contacttheclerk.

Vehicle repossessed by lienholder prior to January 1, ______ .

Date repossessed ____________________________ Lienholder: _____________ (Code N)

Nonresident of Kentucky on January 1, _____ (Copy of proof of nonresidence required.)

Date moved _______________________ Date returned _____________________ (Code N)

Nonresident military personnel (Copy of military residential affidavit or wage/earning statement showing another state as residency required.)(Code N)

Apportioned Plate (Code N)

Truck	Reg. Code 21 or	33	Plate # 979 _____________________
Trailer (Copy of proof provided)		 IFTA license  Login sheet or book  Cab card  Lease Agreement

High mileage, according to guide, on January 1, ______. Mileage as of January 1: ________________

Damaged (physically or mechanically) prior to January 1, ______. (Description attached.)

 Farm Trailer (copy of proof provided showing depreciation for trailer)  IRS Sch F & Form 4562(depreciation schedule)

Corporate return IRS Form 4562(depreciation schedule)

 Other __________________________________________________________________________________________

 Vehicle Assessment NOT Updated:** Reason __________________________________________________________

Signature _____________________________

**In accordance with KRS 131.110 the assessment shall be due and payable if not protested in writing to the Department within sixty (60) days from the date of the notice and provide documentation setting forth the grounds upon which the protest is made.

I, _________________________________________ , hereby swear (affirm) under penalty of perjury that the information above is

true and correct. I further request that the property taxes on the above listed vehicle should be corrected/exonerated for the assessment date(s) of January 1, ______ .

Signature _____________________________ Date __________________________

Witness _______________________________ County ____________________ Date ___________________________

It is now ordered, under the authority of Kentucky Revised Statutes 133.110 and 133.130, that shall be corrected in accordance with Department of Revenue policy based on information listed above.

Signature of Authorized Agent

County

Date

The above signature authorizes the clerk to reverse the ad valorem tax (if paid) from the system. The PVA office shall correct the tax segment and inform the clerk of the next step.