Form C2 "Application for Refund" - Western Australia, Australia

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Government of Western Australia
C2
Department of Transport
Application for Refund
Complete the relevant sections of this form and sign in Section 5 overleaf. Print clearly in ink using BLOCK letters.
Note: A refund cannot be processed for your driver’s or vehicle licence if it is currently subject to a fine suspension, an outstanding vehicle transfer
fee or transfer/plate penalty or if any debt under a Time to Pay arrangement with the Fines Enforcement Registry has not been cleared.
Postal Address: Driver and Vehicle Services, GPO Box R1290, Perth, WA 6844
SECTION 1 - APPLICANT DETAILS
SECTION 4 - CONTINUED
r
FAMILY NAME/COMPANY NAME
Concession
Pensioner Concession Card (maximum rate*)
FIRST NAME
Commonwealth Seniors Health Card
(also requires WA Seniors Card)
OTHER NAME/S
DVA Veteran Card (Gold) printed with TPI or EDA
Letter from DVA certifying the applicant has been assessed at
60 or more impairment points under the Military Rehabilitation
DATE OF BIRTH
DRIVER’S LICENCE NUMBER
/
/
and Compensation Act 2004 (MRCA)
WA Seniors Card
PHONE NUMBER
MOBILE NUMBER
CARD NUMBER
EMAIL ADDRESS
CARD GRANT DATE
/
/
POSTAL ADDRESS
CARD NUMBER
CARD GRANT DATE
SUBURB/COUNTRY
/
/
STATE
POST CODE
If Concession Application (C1) form has not been completed please
SECTION 2 - REFUND TYPE
complete and attach to this form. The C1 can be downloaded online at
www.transport.wa.gov.au/dvs.
DRIVER’S LICENCE
VEHICLE LICENCE
OTHER
DVA Veteran Card (Gold) concessions - a letter from Veterans’
SECTION 3 - VEHICLE DETAILS IF APPLICABLE
Affairs confirming the date of grant must also be presented.
PLATE NUMBER
*To be eligible for a 100% vehicle licence concession a letter from
Department of Human Services (Centrelink) must be presented stating
you are in receipt of maximum rate disability or carer pension or if
the applicant was entitled to the maximum rate of Disability Support
YEAR
MAKE
Pension prior to the Age Pension, a Concession Entitlement Verification
(E113) form endorsed by Centrelink. A certified copy of both sides of
the concession card is required if submitting this application by mail.
VIN/CHASSIS
Deceased estate
NAME OF DECEASED
SECTION 4 - REASON FOR REFUND
Vehicle plates surrendered
DATE DECEASED
/
/
DATE PLATES RETURNED
/
/
DRIVER’S LICENCE NUMBER OF DECEASED
OFFICE
Attach certified copy of death certificate with this application form
(a refund can only be issued to the estate of the deceased).
IF ACCIDENT/STOLEN: DATE OF INCIDENT
Driver’s licence voluntary surrender
/
/
DATE SURRENDERED
If plates have been returned to another Australian licensing jurisdiction,
/
/
the plate receipt must be attached to this form in order for a refund to
be processed.
OFFICE
Note: If the vehicle has been sold to an interstate purchaser with the
WA plates attached you will not be eligible for a refund. If the plates
have been returned as a result of an accident or they have been
If a ‘Variation or Surrender of Driver‘s Licence Application’ (E55)
stolen, please provide either:
form has not been completed please complete and attach to this
• a letter from your insurer showing the plate number, date of
form.
incident and if the vehicle was a write-off; or
The E55 can be downloaded online at www.transport.wa.gov.au/dvs.
• a police report showing the plate number and date of incident; or
• an online crash report showing the plate number and date of
incident.
Last updated: 04.02.2020
Government of Western Australia
C2
Department of Transport
Application for Refund
Complete the relevant sections of this form and sign in Section 5 overleaf. Print clearly in ink using BLOCK letters.
Note: A refund cannot be processed for your driver’s or vehicle licence if it is currently subject to a fine suspension, an outstanding vehicle transfer
fee or transfer/plate penalty or if any debt under a Time to Pay arrangement with the Fines Enforcement Registry has not been cleared.
Postal Address: Driver and Vehicle Services, GPO Box R1290, Perth, WA 6844
SECTION 1 - APPLICANT DETAILS
SECTION 4 - CONTINUED
r
FAMILY NAME/COMPANY NAME
Concession
Pensioner Concession Card (maximum rate*)
FIRST NAME
Commonwealth Seniors Health Card
(also requires WA Seniors Card)
OTHER NAME/S
DVA Veteran Card (Gold) printed with TPI or EDA
Letter from DVA certifying the applicant has been assessed at
60 or more impairment points under the Military Rehabilitation
DATE OF BIRTH
DRIVER’S LICENCE NUMBER
/
/
and Compensation Act 2004 (MRCA)
WA Seniors Card
PHONE NUMBER
MOBILE NUMBER
CARD NUMBER
EMAIL ADDRESS
CARD GRANT DATE
/
/
POSTAL ADDRESS
CARD NUMBER
CARD GRANT DATE
SUBURB/COUNTRY
/
/
STATE
POST CODE
If Concession Application (C1) form has not been completed please
SECTION 2 - REFUND TYPE
complete and attach to this form. The C1 can be downloaded online at
www.transport.wa.gov.au/dvs.
DRIVER’S LICENCE
VEHICLE LICENCE
OTHER
DVA Veteran Card (Gold) concessions - a letter from Veterans’
SECTION 3 - VEHICLE DETAILS IF APPLICABLE
Affairs confirming the date of grant must also be presented.
PLATE NUMBER
*To be eligible for a 100% vehicle licence concession a letter from
Department of Human Services (Centrelink) must be presented stating
you are in receipt of maximum rate disability or carer pension or if
the applicant was entitled to the maximum rate of Disability Support
YEAR
MAKE
Pension prior to the Age Pension, a Concession Entitlement Verification
(E113) form endorsed by Centrelink. A certified copy of both sides of
the concession card is required if submitting this application by mail.
VIN/CHASSIS
Deceased estate
NAME OF DECEASED
SECTION 4 - REASON FOR REFUND
Vehicle plates surrendered
DATE DECEASED
/
/
DATE PLATES RETURNED
/
/
DRIVER’S LICENCE NUMBER OF DECEASED
OFFICE
Attach certified copy of death certificate with this application form
(a refund can only be issued to the estate of the deceased).
IF ACCIDENT/STOLEN: DATE OF INCIDENT
Driver’s licence voluntary surrender
/
/
DATE SURRENDERED
If plates have been returned to another Australian licensing jurisdiction,
/
/
the plate receipt must be attached to this form in order for a refund to
be processed.
OFFICE
Note: If the vehicle has been sold to an interstate purchaser with the
WA plates attached you will not be eligible for a refund. If the plates
have been returned as a result of an accident or they have been
If a ‘Variation or Surrender of Driver‘s Licence Application’ (E55)
stolen, please provide either:
form has not been completed please complete and attach to this
• a letter from your insurer showing the plate number, date of
form.
incident and if the vehicle was a write-off; or
The E55 can be downloaded online at www.transport.wa.gov.au/dvs.
• a police report showing the plate number and date of incident; or
• an online crash report showing the plate number and date of
incident.
Last updated: 04.02.2020
SECTION 4 - CONTINUED
SECTION 6 - FURTHER DETAILS
Use this section if additional space is required or you are requested
Deal cancelled
.
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
AGENT’S SIGNATURE
PAYMENT TYPE
DATE
DATE
/
/
/
/
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