Form Dmv-Rs-01 - Refund Request Application
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2GOVERNMENT OF THE DISTRICT OF COLUMBIA
DEPARTMENT OF MOTOR VEHICLES
REFUND REQUEST APPLICATION
Date of Request: _____________________
Customer Information
First Name:
Middle
Last
Street
City
State
Zip Code
Telephone Number
DL or ID Card Number
E-mail Address
Telephone Number
City
VIN
Tag Number
Tag Surrender Date
Tag Expiration Date
A refund has been requested for the following reason(s): (Refunds must be requested within six-months of payment or
six-months from tag surrender date).
Duplicate Payment
Excise Tax
Late Inspection Fee
Transfer Tags
Unused Registration
Registration Vehicle Weight
Other:
Please allow 6 – 8 weeks for the processing of a refund request. Refunds for unused vehicle registrations are allocated in
six-month increments and not to exceed eighteen months (on a two-year registration), rounding down. All refund requests
must include proof of payment: (i.e. a copy of the front and back of the cancelled check, money order or a copy of the
credit card statement).
FOR DMV OFFICIAL USE ONLY
Original Cost
Total Months Approved
Refund Amount Requested:
Refund Amount Approved
$
$
$
Transaction
Code
Amount
Transaction Number
Account Number
$
Excise Tax
9480
$
Inspection
9214
$
Registration
9151
$
Other:
$
Commodity Code:
223
Index Code:
R0100
Total Amount
Service Center Location:
CSR Signature and Date:
Supervisor/Manager Signature and Date:
Quality Control Reviewer Signature and Date:
AFO Representative Signature and Date:
If you have any questions call our Customer Service Center at 311 in DC or 202-737-4404 or visit our website:
To report waste, fraud and abuse by any DC Government agency or official, call the DC Inspector General at 1-800-521-1639.
DMV-RS-01 Rev. 09/04/08
Distribution: White Copy (DMV) - Canary Copy (Customer)
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Parent category: Legal