VEHICLE REGISTRATION REFUND APPLICATION VEHICLE INFORMATION PLATE NUMBERPurpose: Use this form to request a refund of the DMV registration fee when vehicle tags are returned to DMV and have at least 6-full months remaining on the registration. Instructions: Submit this form and your license plates to any Customer Service Center, or mail the form and license plates to the Special Registration Work Center at the above address. NOTE: Your refund will be mailed to you at the address DMV has in their system. If your address has recently changed, update your address with DMV prior to submitting this request. Read the Registration Refund Information below before completing this form. Save a copy of this form and contact your local county/city/town for complete information about your eligibility for refunds of local license fees. CERTIFICATION I/We certify that this vehicle has been sold, disposed of, and/or will not be used on the roads and highways of Virginia without proper registration. I/We further certify and affirm that all information presented in this form is true and correct, that any documents I/we have presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. I/We make this certification and affirmation under penalty of perjury and I/we understand that knowingly making a false statement or representation on this form is a criminal violation. OWNER SIGNATURE DATE (mm/dd/yyyy) DATE (mm/dd/yyyy) CO-OWNER SIGNATURE CHECK ONE AND SIGN BELOW (if applicable) EXECUTOR POWER OF ATTORNEY LEGAL HEIR ADMINISTRATOR OF ESTATE DATE (mm/dd/yyyy) OWNER SIGNATUREFMS 210 (10/10/2018) ZIP CODE STATE TITLE NUMBER MAKE YEAR EXPIRATION DATE (mm/dd/yyyy) APPLICANT INFORMATION NAME EIN/DRIVER LICENSE NUMBER OR SSN MAILING ADDRESS CITY If your refund check does not arrive within 30 days from the date of your application, write to: DMV Refund Section Financial Management Services P.O. Box 25700 Richmond, Virginia 23260. Refund amounts are based on each 6 full months remaining in the registration period. No refunds are made if less than 6 full months remain in the registration period. A $5.00 processing fee will be deducted from your refund if none of the registration period has passed. REGISTRATION REFUND INFORMATION American LegalNet, Inc. www.FormsWorkFlow.com