Affidavit for purchaser

Qualified Purchaser of an Electric Bicycle Affidavit

First Name

Last Name

Middle Initial

Address

Street Address

City

State

Zip Code

If a current, unexpired Colorado driver license or Colorado identification card number is unavailable, you may provide one of the options listed below for the retailer to review to verify Colorado residency. All documents must be dated within three months from the date of the purchase of a qualified electric bicycle. Please check which alternate proof of residency documentation was provided to the retailer to review:

Computer-generated bill (utility, credit card, doctor, hospital, etc.)

Printed bank statement

Pre-printed pay stub

First-class mail (from a government agency or court)

Current homeowner’s, renter’s, or motor vehicle insurance policy

Mortgage, lease, or rental contract

Transcript or report card from an accredited school

Motor vehicle registration

U S P S Change of Address Form CNL107

D D Form 214

If you are unhoused in Colorado and receiving services from a government agency or nonprofit organization, a dated letter on the organization’s letterhead stating your situation may be accepted in place of one of the above documents.

I attest that I am a Colorado resident who has not previously purchased a qualified electric bicycle that was discounted by a qualified retailer in the same calendar year.

Date / Time

Signature

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Qualified Purchaser of an Electric Bicycle Affidavit

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