Affidavit for Wheel Tax Exemption (Knox County) 2015

Applying for a wheel tax exemption by an affiant who is eligible to receive that exemption requires the execution of the following affidavit.

Extracted Text for Proper Search

2016 Affidavit 	
Foster D. Arnett, Jr. 
Knox  Coun ty C lerk 
Post Office Box 1566 Knoxville, TN 37901 (865)215-2385 	www.knoxcounty.org/clerk	 	  
Affidavit for Wheel Tax Exemption  
 
      	
 Motor Vehicle Division  Pursuant to Knox County Charter Section 58 -1 & T.C.A. § 5 -8-102	 	
Please c omplete this  affidavit , in its  entirety,  and return  it with r egis trat ion  or t ag r enewa l. 
         
        
Registered Owner Information:	 	
 
Na me:  _______________________________________________________________  Date of Birth:  ____________________  
(Print  exactly  as shown  on title/regis tration) 
 
A ddress : ________________________________________  City:  ________________________  Zip : ____________________ 
 
Ph one : ____________________  
 
Vehicle Information:	   M ak e: __________Year:  __________ Model:  __________  Cu rren t Pla te #: ____________________   
 
Basis for Exemption:  (Che ck one)  	
 	
 	Registered  owner/owners  who is  65  years old  or older  	AND	 has  a  co mbin ed annual income  equal  to or  less than 
$16,110.00  per year. 	
     $30.00 EXEMPTION   	
 	Documen tati on r equired	:  Driver’s License  or bir th c ertificate, 	AND	 one (1) of th e fo llowin g for w hic h  yo u qu alify:  
      Incom e Ta x Ret urn – (	
1040A form	) 	
OR  Social Secu rity Statement  from 2014  (	if 1040A income tax form was  not filed	) 	
 	
 	Registered  owner /owners  who has been  certified as totally  disabled by  the Soc ial  Se curity  Admini stration  
or  the U .S. Dept. of Veteran’s Affairs 	
AND	 has  a combined  annual income  equal to or  less  than $16,110.00 
per ye ar.      $30.00 EXEMPTION  	
Documen tati on r equired	:  Dr iver’s Lic ense or bir th c ertificate 	AND	 one (1)  of the followi ng f or wh ich	   	
you qu alify:    Award  of SSI  (supple mental security in come)	 
   	
  Award  of SSD  (social secu rity disa bility)	 
   	
  Award of  Disabled  VA	 	
 	
 	Registered  owner/owners  of the  vehicle  who  are  active duty  memb ers of  the  Unit ed States  Ar my , Navy, Marine  
Corp s, Air  Force,  and Coast Guard  	
OR	 membe rs of  the  Ar my Rese rve, Naval Rese rve, Marine Corps Reserv e, 
Air  Force  Reserve, Coast Guard Rese rve, Ar my National  Gua rd and  Air Nat ional  Guard who  are called to  full -
time  active  duty serv ice.       $36.00 EXEMPTION  	
Documen tati on r equired	:  Copy of  Stationing Orders (must reflect full-time active duty status for reserve/national guard members)  
 	
 	Re gistered  owner is  a veteran who  has  a 100%  permanent  total disability  from  a se rvice -connect ed cause  	OR	 
is a  former p risoner  of  wa r, as d etermin ed by the  U.S.  Dept. of  Veterans  Affairs .      $36.00 EXEMPTION  	
Documen tati on r equire d:	  D D214 Certific ate or other  appropriate  VA related  forms 
 	
 	School bus  under contra ct with Kn ox County  Board of Education .     $36.00 EXEMPTION  	
Documen tati on r equired	:   Certification f rom Knox C ounty  Sch ools	  
 
 
 
I  ce rtify  th at the fo regoi ng s tateme nts are  true a nd correct to the be st of my knowledg e and u nderstandi ng.  I 
fu rthe r a ckn owled ge th at if the b asis for  m y exempt ion is in  pa rt due t o limited income tha t I have  disclos ed a nd 
attached h ereto any and a ll source s of in come for  myself and any o ther ow ner of such moto r vehicl e.
 	
 
 
 
____ __________________________________________                 _______________              _______________________________________ 
Signature  of  Applicant                                                                        Date                                    Clerk Signature   
Revised 12/19/2013