State Form 7669 (R2 / 7-07) Indiana Department of Revenue SWORN AFFIDAVIT FORM • Sworn Affidavit Form signed by seller is due at time of Application for Registration. • For assistance call (317)232-1497 • Mail Sworn Affidavit to: Indiana Department of Revenue Tax Administration/Support-Aeronautics P.O. Box 644 Indianapolis, Indiana 46206-0644 SELLER: Name (Last, First, Middle Initial) Street Address City State Zip Code State Zip Code PURCHASER: Name (Last, First, Middle Initial) Street Address City DESCRIPTION OF AIRCRAFT PURCHASE: FAA Number N Year of Mfg. Serial Number Aircraft Make Date of Purchase (Month, Day, Year) Aircraft Model DESCRIPTION OF TRADE: (must be an aircraft or aircraft parts): FAA Number N Year of Mfg. Aircraft Make Serial Number Aircraft Model SUMMARY: Aircraft Selling Price $ Subtract Aircraft Trade Value $ Amount Subject to Sales/Use Tax $ I hereby verify, under penalty of perjury, that the total price paid for the above described aircraft represents the true amount collected for the sale of the aircraft. This statement is made for the purpose of providing a value for use by the Indiana Department of Revenue in determining the purchaser’s Sales/Use Tax. Date (Month, Day, Year) _________________ Signature of Seller ______________________________________________ Print Name of Seller _____________________________________________ American LegalNet, Inc. www.FormsWorkflow.com