Form T-126 - Refund Request - Registration, Title &/or Insurance Fees
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2Form T-126 (Rev. 11-2009)
Georgia Department of Revenue (DOR) Refund Request – Registration, Title &/or Insurance Fees
A. Vehicle Owner/Requestor Information
Full, Legal Name of Person/Business Requesting a Refund
Date
Street Address
City
State
Zip Code
Daytime Telephone Number
Customer #1 ID Number
Social Security # (if Individual &
Driver’s License # & State of
EIN (Employer ID # if business)
(from original payment receipt)
payment made to DOR)
Issue (if Individual & payment
made to County Tag Office)
B. Vehicle Information
Vehicle Year
Vehicle Make
Current Tag Number
Vehicle ID Number/Manufacturer’s ID Number
C. I request a refund of the following fee paid directly to the St ate of Georgia or to my County Tag Agent on behalf of the State of
Georgia for the following authorized reason(s). Please check applicable reason(s). Receipt must accompany refund request.
State Fee Type
Amount
County Where Fees Paid
Date Fees Paid
Registration Fee
$
Prestige/Special Tag Mfg. Fee/Renewal Fee
$
Title Application Fee
$
Title Application Penalty Fee
$
Title Special Handling Fee
$
Insurance Lapse Fee
$
Insurance Re-Instatement Fee
$
State Fee Type
Reason(s) for Refund Request
Registration Fee
(1) Existing license plate to transfer, new tag not needed.
(2) Vehicle not owned during the owner’s registration period.
(3) Owner paid registration fee for license plate and qualified for a free
license plate in same plate category.
Prestige/Special Tag Mfg. Fee/Renewal Fee
(4) Minimum number of applications not received and special license
plate will not be manufactured.
(5) Prestige license plate combination disapproved or manufactured
incorrectly and owner no longer wants a prestige license plate.
(6) Owner paid manufacturing and/or special tag renewal fee for special
license plate and qualified for a free license plate in same special
license plate category.
(7) Special/Prestige tag wa s issued to wrong customer.
(8) Owner is not eligible for special license plate category.
Title Application, Special Handling, Penalty Fee
(9) Georgia does not title this vehicle type/year.
(10) Vehicle owner is not a Georgia resident.
(11) Vehicle owner is a state/federal agency.
(12) Title Approval/Rejection not expedited.
(13) Penalty fee is not due.
Insurance Fee
(14) There was not a lapse in insurance coverage.
(15) Restoration fee not due because there was not a lapse in insurance
coverage, termination of insurance and/or fee was received by
deadline.
D.
Signature
Signature of Person Requesting Refund
Printed Name & Title if Refund Request is for a Business
Instructions are on the next page.
DOR/PC-MV forms and information are available on the Internet at:
.
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