Fillable Tlc Refund Claim Form printable pdf download

Tlc Refund Claim Form

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________________________________________________________________________________________________

TLC REFUND CLAIM FORM

for refund please check one

Reason

I appeared at a hearing and my case was dismissed.

I filed an appeal and the decision on my initial case was reversed or dismissed.

For other reasons, please explain: ___________________________________________________

(Attach additional pages if needed)

(Please note as stated on all license application documents, application fees are not refundable).

Please print

clearly

Last name: ___________________________________________

First name: ___________________________________________

Middle Initial (M.I.): _____

Address: _____________________________________________________________________________

(Street)

(Apt. #)

_____________________________________________________________________________________

(City)

(State)

(Zip Code)

Telephone #: (____ ____ ____) ____ ____ ____ - ____ ____ ____ ____

TLC License #: ____ ____ ____ ____ ____ ____ ____

Expiration Date: ____ /____ /____

(For which you are claiming a refund)

Amount claimed as refund: $ __________

All claims must have copies of the relevant supporting documents attached:

Notice of Decision (for claims involving hearings and appeals);

Copy of TLC receipt for payment (if paid with currency in person); and

Copy of front and back of cleared money order or check and/or credit card receipt

Please keep all original documents with your records.

Please mail to: New York City Taxi & Limousine Commission

Attention: Refund Claim Unit

33 Beaver Street, 19

Floor

New York, NY 10004

Your Signature: _____________________________________________

Date: ____ / ____ / ____

Incomplete or incorrect forms will not be processed. If you are entitled to a refund

PLEASE NOTE:

check, a check will be mailed to you in about 6-8 weeks. A check will not be delivered to an

incorrect address, which may delay your refund.

Make certain copies of all receipts are attached to this claim.

TLC Refund Claim Form 4.11.16

Tlc Refund Claim Form

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