Unredeemed Voucher Remittance Form printable pdf download

State of Tennessee

Department of Commerce and Insurance

Scrap Metal Dealer Registration Program

500 James Robertson Parkway

Nashville, TN 37243

(615) 7411741 FAX 6152531179

SCRAP METAL DEALERS

UNREDEEMED VOUCHER REMITTANCE FORM

Pursuant to Tennessee Code Annotated, Section 629104(c) (2) (B) (ii), when payment for scrap metal is made by

voucher and such voucher is not redeemed within six (6) months of the date of the transaction, the voucher expires and

may no longer be honored by the dealer. Within (1) year from the date of the voucher’s expiration date, the dealer must

transmit the transaction amount to the Department of Commerce and Insurance at the address shown above.

Unredeemed voucher funds may be transmitted to the department in the same manner as dealer registration and

renewal fees.

Date Submitted: ________________________________________________________________________________________

Scrap Metal Dealer Name:_________________________________________________________________________________

Scrap Metal Dealer Registration Number: _____________________________________________________________________

If a business entity, name of duly authorized natural person completing this transmittal:

______________________________________________________________________________________________________

Street Address of Business Location: ________________________________________________________________________

City: ____________________________________________________, TN

Zip Code:_______________________

Mailing address if different from above:_______________________________________________________________________

City: ____________________________________________________, TN

Zip Code:_______________________

Phone number: _________________________________________________________________________________________

Email address: (optional) _________________________________________________________________________________

Date of Voucher

Amount of

Payee of Voucher

Scrap Metal Description

Issuance/Expiration

Voucher

TOTAL

Submitted:

This form must be typed or legibly written in ink.

Unredeemed Voucher Remittance Form