Application For Refund - Western Australia Department Of Transport
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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 5 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 a fine suspension, an outstanding vehicle
transfer fee or transfer/plate penalty or if any debt under a Time to Pay arrangement with the Fines Enforcement Registry has not been cleared.
Postal Address: Driver and Vehicle Services, GPO Box R1290, Perth, WA 6844
SECTION 1 - APPLICANT DETAILS
SECTION 4 - CONTINUED
FAMILY NAME/COMPANY 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)
Veterans’ Affairs (certified 60+ impairment points)
DATE OF BIRTH
DRIVER’S LICENCE NUMBER
/
/
WA Seniors Card
PHONE NUMBER
MOBILE NUMBER
CARD NUMBER
EMAIL ADDRESS
CARD GRANT DATE
/
/
POSTAL ADDRESS
CARD NUMBER
CARD GRANT DATE
/
/
SUBURB/COUNTRY
If Concession Application (Form C1) has not been completed please
STATE
POST CODE
complete and attach to this form. The C1 form can be downloaded
online at
SECTION 2 - REFUND TYPE
*To be eligible for 100% vehicle licence concession a letter from
DRIVER’S LICENCE
Centrelink must also be presented stating you are in receipt of
VEHICLE LICENCE
maximum rate disability or carer pension (please refer to concession
OTHER
application form C1 for further details). A certified copy of both sides of
the concession card is required if submitting this application by mail.
SECTION 3 - VEHICLE DETAILS IF APPLICABLE
PLATE NUMBER
Deceased estate
NAME OF DECEASED
MAKE
YEAR
DATE DECEASED
VIN/CHASSIS
/
/
DRIVER’S LICENCE NUMBER OF DECEASED
SECTION 4 - REASON FOR REFUND
Attach certified copy of death certificate with this application form
Vehicle plates surrendered
(a refund can only be issued to the estate of the deceased).
DATE PLATES RETURNED
/
/
Driver’s licence voluntary surrender
OFFICE
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
If a ‘Variation or Surrender of Driver‘s Licence Application’
for a refund to be processed.
(Form E55) has not been completed please complete and
attach to this form. The E55 form can be downloaded online at
If the plates have been returned as a result of an accident or they
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: 24.03.2017
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