Owner:
Co-Owner:
Address:
.
.
.
Cell Phone:
Make: Model:
Title #
Plate #
Make: Model:
Title #
Plate #
Make: Model:
Title #
Plate #
2011 105,001 +
.
Unaltered inspection receipt 2012 95,001 +
.
Oil change or service repair receipt from a service station 2006 155,001 + 2013 85 001 +
.
Odometer certification certificate 2007 150,001 + 2014 70,001 +
2008 140,001 + 2015 60,001 +
2009 130,001 +
2010 120,001 +
2005 &
Older
Does Not
Qualify
2016 &
Newer
45,001 +
Vehicle Information
High Mileage Chart
You MUST attach a copy of one of the following documents.
Year:
Year:
VIN #:
Email Address:
Home Phone:
MONTGOMERY COUNTY, VIRGINIA
Helen P. Royal, Master Commissioner of the Revenue
755 Roanoke St. Suite 1A Christiansburg, VA 24073
HIGH MILEAGE APPLICATION
Phone 540-382-5710 Fax 540-381-6838
Documentation
Complete, sign, date & return (to the address above) this High Mileage Application form and the required
documentation or evidence to support your application.
Email: personalproperty@montgomerycountyva.gov
2019
I declare, under penalty of perjury, (1) that the foregoing information is complete, true and correct to the best of my knowledge and belief,
and (2) that I am the owner or a member, partner, executive officer, or other person specifically authorized in writing to sign.
The Commissioner of the Revenue may require the submission of additional information or other evidence deemed
necessary for a proper and equitable determination of the Application.
High Mileage Application MUST BE FILED EACH YEAR by May 1st to continue to receive a reduction.
Additional Owner Information
Year:
VIN #:
Documented Mileage:
Co-Owner Signature
Print Name
Date
Documented Mileage:
Owner Signature
Print Name
Date
VIN #:
Documented Mileage:
Documentation must have VIN #
Applications received without proper documentation cannot be accepted or
processed.
Certification
The owner(s) must sign and date this form. If the owner is an entity such as a trust, partnership, limited liability company, or
corporation, it must be signed by a member, partner, executive officer, or other person specifically authorized in writing by the
trust, partnership, limited liability company, or corporation to sign.
click to sign
signature
click to edit
click to sign
signature
click to edit