Form Pwd 1084 - Void Request Form
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1BRITS - VOID REQUEST FORM
Order Number: _____________________________
Void Authorization Code #: ____________________________
Order Date: ________________________________
Post Process Date Void
User ID: ___________________________________
(HQ Staff Only) Date Voided: __________________________
(HQ Staff Signature) Voided By: __________________________
Phone #: (______)___________________________
Office/Location Name: _______________________________________
Select the Reason for the Void:
____ Wrong vessel/motor/dealer processed
____ Incorrect vessel length affecting registration fee
____ Wrong sales date entered
____ Misunderstood transaction request
____ Wrong sales price entered
____ Customer withdrew request
____ Wrong trade-in amount entered/not credited
____ Other, explain ___________________________________
Comments: _________________________________________________________________________________________
List transaction(s) to be voided and complete all data fields (attach additional sheets if needed):
Check
TX or PBO
Transaction
Document
Not
Not Yet
Lost
One
Number
Description
Description
Returned Applicable
Fulfilled
Destroyed
B
M
Title
PB Operator
ID Card
Dealer
Decal
B
M
Title
PB Operator
ID Card
Dealer
Decal
B
M
Title
PB Operator
ID Card
Dealer
Decal
Is there a follow-up/correcting transaction? Select only one.
_____ Already processed - Enter follow-up/correcting transaction number. ______________________
_____ None required
_____ Action required - explain what action is required: __________________________________________________
__________________________________________________________________________________________
Is there a refund due?
_____ No, the void has been completed.
_____ No, the credit should be used to process a follow-up/correcting transaction.
_____ Yes, refund the owner of record.
_____ Yes, refund the remitter, not the owner of record.
Explanation required by Office: ________________________________________________________________
Name: _________________________________
Address: _________________________________________
City, State, Zip:
_____ Yes, refund TAC Office.
I hereby certify that all statements in this document are true and correct to the best of my knowledge and belief.
Processor's Signature:____________________________________________ Date:___________________________
Supervisor's Signature: ____________________________________________ Date: ________________________
PWD 1084 – A0900 (7/14)
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Parent category: Legal