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BOE-146-TSG (BACK) (9-12)

STATEMENT OF DELIVERY (to be completed by seller)

NOTICE TO SELLER

If you are delivering the property to the tribal government at the tribal business location by your own facilities, you may utilize this statement of delivery to document delivery at the principal place where the tribal government meets to conduct tribal business (tribal business location) when the tribal government is an officially recognized Indian tribe that does not have a reservation or the tribal business location cannot be on its Indian tribe’s reservation because the reservation does not have a building in which the tribal government can meet or the reservation lacks one or more essential utility services or mail service from the United States Post Office. It is recommended that you also complete the Notary Statement below to document delivery of the property to the tribal government at the tribal business location. The Notary Statement may be completed by a California notary public or by a duly authorized tribal official or his or her designee. If you are delivering the property to the tribal government at the tribal business location by utilizing a common carrier or a contract carrier, you do not need to complete the Statement of Delivery or the Notary Statement. Instead, you should retain your bill of lading or other shipping documents as proof of delivery to the tribal business location along with your sales contract or sales invoice indicating ownership transferred at the tribal business location. You may verify the tribal business location on the BOE website at www.boe.ca.gov/sutax/indianLandSales.htm.

I hereby certify, under penalty of perjury under the laws of the State of California, that the below described tangible personal property was delivered to the purchaser at the tribal business location on the date and at the place stated below. If the property is a vehicle, please provide the year, make, model, and identification number in addition to a description of the property.

DESCRIPTION OF PROPERTY SOLD

INVOICE NUMBER

YEAR

MAKE

MODEL

VIN/LIC NUMBER

NAME OF TRIBE

ADDRESS (street, city, zip code)

DATE OF DELIVERY

NAME OF SELLER

SELLER’S PERMIT NUMBER

DAYTIME TELEPHONE NUMBER

STREET ADDRESS

CITY

STATE

ZIP CODE

I have delivered the above-described tangible personal property to the purchaser named above.

NAME (please print)

SIGNATURE

DATE

NOTARY STATEMENT (to be completed by California notary public or authorized tribal representative)

State of California

County of

___________________________________________________________________________________

On ________________________

before me, _____________________________________ personally appeared

(date)

(name and title)

both

_______________________________________________________________________________________

(name of seller or seller’s representative)

and

____________________________________________________________________________________________________________________ (name of purchaser or purchaser’s representative)

who proved to me on the basis of satisfactory evidence to the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that they executed the same in their authorized capacity, and that by their signature on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under penalty of perjury under the laws of the State of California that the foregoing paragraph is true and

correct. WITNESS my hand and official seal (if applicable). S i g n a t u r e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Fraudulent use of this statement to avoid the payment of California sales and use tax can result in severe penalties.

JANUARY 2013P| SALES TO AMERICAN INDIANS AND SALES IN INDIAN COUNTRY

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