Fillable 2021 High Mileage Application (Montgomery County, Virginia)

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2021 High Mileage Application (Montgomery County, Virginia)

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The 2021 High Mileage Application (Montgomery County, Virginia) form is 1 page long and contains:

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  • 37 other fields

Country of origin: US
File type: PDF

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Owner:
Co-Owner:
Address:
.
.
.
Cell Phone:
Make: Model:
Title #
Plate #
Make: Model:
Title #
Plate #
Make: Model:
Title #
Plate #
2013 105,001 +
.
Unaltered inspection receipt 2014 95,001 +
.
Oil change or service repair receipt from a service station 2008 155,001 + 2015 85 001 +
.
Odometer certification certificate 2009 150,001 + 2016 70,001 +
2010 140,001 + 2017 60,001 +
2011 130,001 +
2012 120,001 +
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.
Co-Owner Signature
Print Name
Date
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:
Documentation
Complete, sign, date & return (to the address above) this High Mileage Application form and the required
documentation or evidence to support your application.
Last 4 Digits of SSN:
Property ID:
Last 4 Digits of SSN:
2021
Email Address:
Home Phone:
Work Phone:
2007 &
Older
Does Not
Qualify
2018 &
Newer
45,001 +
Vehicle Information
High Mileage Chart
You MUST attach a copy of one of the following documents.
Year:
Year:
VIN #:
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2021 High Mileage Application (Montgomery County, Virginia)

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Completed 5 July 2021

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