Fillable Application for Refund (Services Australia)

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Application for Refund (Services Australia)

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The Application for Refund (Services Australia) form is 2 pages long and contains:

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  • 12 check-boxes
  • 64 other fields

Country of origin: AUSTRALIA
File type: PDF

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Services Australia, (previously DHS - Department of Human Services) is responsible for delivering services relating to health and welfare of Australian citizens. It processes payment of child support other services.

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Government of Western Australia
Department of Transport
r
C2
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 ne 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
Last updated: 04.02.2020
DATE OF BIRTH
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SECTION 4 - CONTINUEDSECTION 1 - APPLICANT DETAILS
SECTION 3 - VEHICLE DETAILS IF APPLICABLE
YEAR
Vehicle plates surrendered
DATE PLATES RETURNED
IF ACCIDENT/STOLEN: DATE OF INCIDENT
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.
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
stolen, please provide either:
• a letter from your insurer showing the plate number, date of
incident and if the vehicle was a write-o; or
• a police report showing the plate number and date of incident; or
• an online crash report showing the plate number and date of
incident.
SECTION 2 - REFUND TYPE
DRIVER’S LICENCE VEHICLE LICENCE
OTHER
CARD GRANT DATE
CARD GRANT DATE
SECTION 4 - REASON FOR REFUND
If Concession Application (C1) form has not been completed please
complete and attach to this form. The C1 can be downloaded online at
www.transport.wa.gov.au/dvs.
DVA Veteran Card (Gold) concessions - a letter from Veterans’
Aairs conrming the date of grant must also be presented.
*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
Pension prior to the Age Pension, a Concession Entitlement Verication
(E113) form endorsed by Centrelink. A certied copy of both sides of
the concession card is required if submitting this application by mail.
PLATE NUMBER
VIN/CHASSIS
Concession
Pensioner Concession Card (maximum rate*)
Commonwealth Seniors Health Card
(also requires WA Seniors Card)
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
and Compensation Act 2004 (MRCA)
WA Seniors Card
DRIVER’S LICENCE NUMBER
MOBILE NUMBERPHONE NUMBER
FAMILY NAME/COMPANY NAME
FIRST NAME
OTHER NAME/S
EMAIL ADDRESS
MAKE
OFFICE
Driver’s licence voluntary surrender
OFFICE
DATE SURRENDERED
If a ‘Variation or Surrender of Driver‘s Licence Application’ (E55)
form has not been completed please complete and attach to this
form.
The E55 can be downloaded online at www.transport.wa.gov.au/dvs.
Deceased estate
NAME OF DECEASED
DATE DECEASED
DRIVER’S LICENCE NUMBER OF DECEASED
Attach certied copy of death certicate with this application form
(a refund can only be issued to the estate of the deceased).
CARD NUMBER
CARD NUMBER
POSTAL ADDRESS
SUBURB/COUNTRY
POST CODESTATE
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Deal cancelled
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 benet 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 benet gained and delivery of vehicle was not
taken.
Other refund type
REFUND TYPE - PLEASE COMPLETE SECTION 6 WITH FULL DETAILS
Incorrect payment
RECEIPT NUMBER
PAYMENT DATE
Attach original receipt or bank statement showing payment details
and complete details of the error in section 6.
Use this section if additional space is required or you are requested
to do so
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SECTION 5 - CLAIMANT’S SIGNATURE
SIGNATURE
DATE
If you are submitting this application on behalf of the claimant,
complete this section.
AGENT’S SIGNATURE
DATE
AGENT’S NAME
PAYMENT TYPE
DATE
PAYMENT RECEIPT NUMBER
I declare that the information on this form is true and correct.
I understand that under the Road Trac (Administration) Act 2008,
it is an oence to provide false or misleading information.
SECTION 6 - FURTHER DETAILSSECTION 4 - CONTINUED
OFFICER NAME
OFFICER SIGNATURE
SITE
Relevant records have been checked and updated
Relevant documents attached.
Vehicle or Driver’s Licence is not subject to ne suspension.
Vehicle does not have an outstanding Transfer or Transfer/
Plate penalty.
PENDING AMOUNTS
I certify the details on this application have been veried as
correct and all required paperwork is attached.
OFFICE USE ONLY
RECEIVING OFFICER SIGNATURE
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Application for Refund (Services Australia)

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Completed 19 May 2021

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