Clear form
Utah State Tax Commission
TC-55A
Claim for Refund of Fees or Sales Tax for Motor Vehicles
Rev. 5/05
(Instructions on reverse side)
Name
License plate, permit or assigned number
Address
VIN/HIN
City
State
Zip code
Daytime Telephone no.
1. Amount of sales tax or license fees paid
$
$
2. Correct amount of sales tax or license fee as computed by taxpayer
3. Amount claimed as a refund (subtract amount on line 1 from line 2)
$
I believe that this claim should be allowed for the following reasons: (use reverse side if needed)
Under penalties of perjury, I declare that I have examined this claim and to the best of my knowledge and belief it is true, correct and complete.
Signature
Date
For Motor Vehicle Use Only
Decal #: _________________
Returned plate #: _________________
Registration month/year: ______________
TXID: ______________
For Tax Commission Use Only
Checked by
Date
Approved by
Date
DMV accounting approval
Date
Transaction #: ___________________________________________________________
Total amount of refund
$
$
Motor vehicle fees
Sales tax
as computed by the Utah
$
State Tax Commission
Breakdown of refund by account
Motor Vehicle
Watercraft/Off-highway
Indicate for each account listed below the amount of the refund approved by the examining agent.
Account type
Amount of refund
Account type
Amount of refund
Registration canceled?
Registration fees
$
IRP
$
Yes
No
$
$
Title
DUI
Date canceled: ____________________
$
Driver's Ed.
$
Sales Tax
TXID: ______________
Impound
$
$
Insurance Data
Insurance Revocation
$
$
Personalized Plate Fee
Plate Fee
RPS/Internet Fall Outs
$
$
Other: ____________
Postage
$
$