Application For Refund Form - Government Of Western Australia - Department Of Transport
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2C2
Government of Western Australia
Department of Transport
Application for Refund
Driver and Vehicle Services
Please complete the relevant sections of this form and sign in Section 6 overleaf. Print clearly in ink using BLOCK letters.
Please note a refund cannot be processed for your driver’s or vehicle licence if it is currently subject to fine suspension or there is an
outstanding vehicle transfer fee or transfer/plate penalty.
Postal Address: Driver and Vehicle Services, GPO Box R1290, Perth, WA 6844
SECTION 1 - APPLICANT DETAILS
SECTION 4 - CONTINUED
t
FAMILY NAME
Concession
Centrelink Pension Concession Card (maximum rate*)
FIRST NAME
Commonwealth Seniors Health Card (also requires WA
Seniors Card)
OTHER NAME/S
Department of Veterans’ Affairs DVA Health Card (Gold
Card endorsed TPI/EDA)
DATE OF BIRTH
Veterans’ Affairs (certified 60+ impairment points)
/
/
WA Seniors Card
PHONE NUMBER
CARD NUMBER
EMAIL ADDRESS
POSTAL ADDRESS
CARD GRANT DATE
/
/
CARD NUMBER
SUBURB/COUNTRY
STATE
POST CODE
CARD GRANT DATE
/
/
DRIVER’S LICENCE
If concession application form (C1) has not been completed
please complete and attach to this form. The C1 form can be
SECTION 2 - REFUND TYPE
downloaded online at
DRIVER’S LICENCE
*To be eligible for 100% vehicle licence concession a
letter from Centrelink must also be presented stating you
VEHICLE LICENCE
are in receipt of maximum rate disability or carer pen-
OTHER
sion (please refer to concession application form C1
for further details). A certified copy of both sides of the
SECTION 3 - VEHICLE DETAILS IF APPLICABLE
concession card is required if submitting this application by mail.
PLATE NUMBER
Deceased estate
NAME OF DECEASED
MAKE
YEAR
DATE DECEASED
VIN/CHASSIS
/
/
DRIVER’S LICENCE NUMBER OF DECEASED
SECTION 4 - REASON FOR REFUND
Vehicle plates surrendered
Attach certified copy of death certificate with this application
form (refund can only be issued to the estate of the
DATE PLATES RETURNED
deceased).
/
/
OFFICE
Driver’s licence voluntary surrender
DATE SURRENDERED
/
/
IF ACCIDENT/STOLEN: DATE OF INCIDENT
/
/
OFFICE
If plates have been returned to another Australian licensing
jurisdiction, the plate receipt must be attached to this form in
order for a refund to be processed.
If Variation or Surrender of Driver‘s Licence Application form
(E55) has not been completed please complete and attach to
If the plates have been returned as a result of an accident or they
this form. The E55 form can be downloaded online at
have been stolen, please provide either:
•
a letter from your insurer showing the plate number, date of
incident and if the vehicle was a write-off; or
•
a police report showing the plate number and date of
incident; or
•
an online crash report showing the plate number and date of
incident.
Last updated: 03/05/2016
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