Form Mvr-609a - Claim Of Sales Or Use Tax Payment Under Protest Refund Requested

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North Carolina Division of Motor Vehicles
MVR-609A
(Rev. 09/09)
Claim of Sales or Use Tax Payment Under Protest
Refund Requested
TO: North Carolina Division of Motor Vehicles, Vehicle Registration Section
3148 Mail Service Center
Raleigh NC 27699-3148
919-715-7000
From: Claimants Name
Vehicle Description:
______________________________________________
____________________________
Vehicle Identification Number:
FIRST
MIDDLE
LAST
______________________________________________
Year:
________________
Make :_______________________
ADDRESS
______________________________________________
__________________
License Plate:
CITY
STATE
ZIP CODE
Schedule of Value: ___________________
______________________________________________
Phone Number
Tax Due According to Schedule of Value: ___________
Date Originally Purchased: ______________________
______________________________________________
This vehicle was purchased from:
Claimant’s Signature
Date
_____________________________________________
I agree to furnish any further evidence needed to support this claim.
Seller’s Name
_____________________________________________
ATTENTION: Pursuant to G.S. 105.187.8
Seller’s Address
_____________________________________________
When a purchaser of a motor vehicle returns the motor
City
State
Zip
vehicle to the seller of the motor vehicle within 90 days
after the purchase and receives a vehicle replacement
for the returned vehicle or a refund of the price paid the seller, whether from the seller or the manufacturer of the vehicle, the
purchaser may obtain a refund of the privilege tax paid on the certificate of title issued for the returned motor vehicle.
To obtain a refund, the purchaser must apply to the Division for a refund within 30 days after receiving the replacement vehicle or
refund of the purchase price.
APPLICATION MUST BE SIGNED IN INK BY OWNER AND NOTARIZED.
This application is to request a refund of the payment / overpayment of Highway Use Tax for the reason listed below.
I hereby affirm that I returned the vehicle on ______________________ (date) and authorize the CLAIMANT to receive
the refund indicated. I agree to furnish any further evidence needed to support this claim.
Reason for Highway Use Tax Adjustment Request:
Full Refund pursuant to G.S. 105.187.8 – returned vehicle
Partial Refund
(based on replacement of vehicle,
requesting tax difference between the two vehicles)
PREVIOUS PURCHASER’S SIGNATURE ____________________________________________________
_________________________
Date
Previous Purchaser’s Printed Name: ________________________________________ Previous Purchaser’s Phone Number: _________________
I certify that the following person(s) personally appeared before me this day, each acknowledging to me that he or she voluntarily signed the foregoing
document for the purpose stated therein and in the capacity indicated: __________________________________________(name(s) of principal(s) ).
Notary
Notary Printed
Signature _______________________________________________
or Typed Name ______________________________________________
My Commission Expires _______________________________________
(SEAL)
FOR NCDMV USE ONLY
.
Tax Paid: _____________________
Tax Due: _____________________
Credit Refund: ______________________
Approved By: _________________________________
Date: ______________

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