Tlc Refund Claim Form

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for refund please check one
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
Last name: ___________________________________________
First name: ___________________________________________
Middle Initial (M.I.): _____
Address: _____________________________________________________________________________
(Apt. #)
(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
New York, NY 10004
Your Signature: _____________________________________________
Date: ____ / ____ / ____
Incomplete or incorrect forms will not be processed. If you are entitled to a refund
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


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