Application For Refund - Western Australia Department Of Transport Page 2
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2SECTION 4 - CONTINUED
SECTION 6 - FURTHER DETAILS
Deal cancelled
Use this section if additional space is required or you are requested
.
to do so
Applies to licensed motor vehicle dealer. Only applies to deals
cancelled within 5 business days. Attach the original licence receipt
and the following:
•
A letter from the dealer principal stating the reason for refund,
no benefit gained and prospective purchaser did not take
delivery of the vehicle; and
•
A letter from the prospective purchaser stating fees were paid
by the dealer, no benefit gained and delivery of vehicle was not
taken.
Incorrect payment
PAYMENT DATE
/
/
RECEIPT NUMBER
Attach original receipt or bank statement showing payment details
and complete details of the error in section 6.
Other refund type
REFUND TYPE - PLEASE COMPLETE SECTION 6 WITH FULL DETAILS
SECTION 5 - CLAIMANT’S SIGNATURE
I declare that the information on this form is true and correct.
I understand that under the Road Traffic (Administration) Act 2008,
it is an offence to provide false or misleading information.
SIGNATURE
DATE
/
/
If you are submitting this application on behalf of the claimant,
complete this section.
AGENT’S NAME
PAYMENT RECEIPT NUMBER
PAYMENT TYPE
AGENT’S SIGNATURE
DATE
DATE
/
/
/
/
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