BMV 56165 - Formstack

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Instructions

Provide the reason you are applying for the refund in Section 2 and attach the supporting document proof with this application.
If you are signing on behalf of the applicant, you must provide a photocopy of the document that authorizes you to do so (e.g. POA, executor, company agent, or representative).
If a registration has more than one (1) registrant, only one (1) registrant is required to sign as applicant.
Submit this application and all supporting documents within three (3) years after the date on which the person paid the fee. All requests for refund will be reviewed within thirty (30) business days of receipt. Individuals with approved refund requests will receive a check from the state Auditor; individuals with denied requests will receive a letter explaining the denial.

SECTION 1: REFUND PAYEE INFORMATION

Name*

First Name*

Last Name*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Email*

Applicant(s) Driver’s License Number, Federal ID Number, or Customer UID*

Do not include dashes (-)

SECTION 2: REFUND REASON

Please choose the department associated with this refund:*

Collection Service Fee Driver's License, ID Card, etc. Registrations, Plates, Stickers Titles Titles & Registrations Insurance Reinstatement Fees

Briefly describe the reason for the refund and attach all supporting documentation.*

Attach supporting file

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Attach supporting file (2)

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Attach supporting file (3)

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Attach supporting file (4)

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Attach supporting file (5)

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Date fee was paid*

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Month

Day

Year

Amount of refund claimed by Applicant* $

SECTION 3: VEHICLE / WATERCRAFT INFORMATION

(If the refund involves a vehicle / watercraft, VIN / HIN are required below.)

VEHICLE IDENTIFICATION NUMBER (VIN) / WATERCRAFT IDENTIFICATION NUMBER (HIN):

License Plate Number / Watercraft Registration Number

Add another (1)?

Add another vehicle/watercraft to this transaction

2nd VEHICLE IDENTIFICATION NUMBER (VIN) / WATERCRAFT IDENTIFICATION NUMBER (HIN):

2nd License Plate Number / Watercraft Registration Number

Add another (2)?

Add another vehicle/watercraft to this transaction

3rd VEHICLE IDENTIFICATION NUMBER (VIN) / WATERCRAFT IDENTIFICATION NUMBER (HIN):

3rd License Plate Number / Watercraft Registration Number

Add another (3)?

Add another vehicle/watercraft to this transaction

4th VEHICLE IDENTIFICATION NUMBER (VIN) / WATERCRAFT IDENTIFICATION NUMBER (HIN):

4th License Plate Number / Watercraft Registration Number

Add another (4)?

Add another vehicle/watercraft to this transaction

5th VEHICLE IDENTIFICATION NUMBER (VIN) / WATERCRAFT IDENTIFICATION NUMBER (HIN):

5th License Plate Number / Watercraft Registration Number

Add another (5)?

Add another vehicle/watercraft to this transaction

6th VEHICLE IDENTIFICATION NUMBER (VIN) / WATERCRAFT IDENTIFICATION NUMBER (HIN):

6th License Plate Number / Watercraft Registration Number

Add another (6)?

Add another vehicle/watercraft to this transaction

7th VEHICLE IDENTIFICATION NUMBER (VIN) / WATERCRAFT IDENTIFICATION NUMBER (HIN):

7th License Plate Number / Watercraft Registration Number

Add another (7)?

Add another vehicle/watercraft to this transaction

8th VEHICLE IDENTIFICATION NUMBER (VIN) / WATERCRAFT IDENTIFICATION NUMBER (HIN):

8th License Plate Number / Watercraft Registration Number

Add another (8)?

Add another vehicle/watercraft to this transaction

9th VEHICLE IDENTIFICATION NUMBER (VIN) / WATERCRAFT IDENTIFICATION NUMBER (HIN):

9th License Plate Number / Watercraft Registration Number

Add another (9)?

Add another vehicle/watercraft to this transaction

10th VEHICLE IDENTIFICATION NUMBER (VIN) / WATERCRAFT IDENTIFICATION NUMBER (HIN):

10th License Plate Number / Watercraft Registration Number

SECTION 4: APPLICANT AFFIRMATION

I swear or affirm under the penalties for perjury that I am requesting a refund for the above-listed reason, that a refund has not been previously issued to me for this reason, and that all of the information entered above is true and correct.

Signature of Applicant *

Use your mouse or finger to draw your signature above

Date Signed *

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Month

Day

Year

Printed Name of Applicant*

Relationship to Payee(s) (if other than payee) (Example: agent, POA, executor of estate, agent)

SECTION 5: BMV USE ONLY

Please review the information above to ensure that it is accurately assigned to your department. If it is accurate, please choose your department. Otherwise, choose the correct department and proceed with the approval workflow.

Please CONFIRM the department associated with this refund:*

Collection Service Fee Driver's License, ID Card, etc. Registrations, Plates, Stickers Titles Titles & Registrations Insurance Reinstatement Fees

Comments or reasoning about reassignment

SECTION 6: BMV USE ONLY - Department Review

Approval Amount (If denied, enter 0.)* $

Name of BMV Official*

First Name*

Last Name*

Date of Approval or Denial*

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Month

Day

Year

Department Justification

SECTION 6B: BMV USE ONLY - Title & Registration Selection Only

Approval Amount (If denied, enter 0.)* $

Name of BMV Official*

First Name*

Last Name*

Date of Approval or Denial*

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Month

Day

Year

Registration Justification

SECTION 7: BMV USE ONLY - Finance Review

Refund Decision?*

Approved Denied

Approval Amount (If denied, enter 0.)* $

Date of Approval or Denial*

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Month

Day

Year

Refund ID*

Date of Refund*

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Month

Day

Year

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