Date: _______ / _______ / _______
To: Office of the Secretary of State Please consider claim for refund of $ _______________
Accounting Revenue Department
Refund Section
222 Howlett Building
Springfield, IL 62756
Registrant: Mail To: (If other than registrant)
Reason for Request:
n Cancellation: Return vehicle registration sticker and sworn statement. License Plate # _______________________
(Must have previous year registration in same name. No partial or prorated refunds.)
n Duplicate: Return vehicle registration sticker with photocopy of registration card being used on vehicle.
License Plate #___________________
n
Excess Fee: Submit photocopy of vehicle registration card along with photocopy of front and back of canceled check.
n Benefit Access: License Plate # __________________________Control # ______________________ (Issued by
Secretary of State)
n Driver’s License #: _____________________________________
Explanation:_______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Daytime Telephone #: _________________________________ Signature _____________________________________
SECRETARY OF STATE
Consideration for Refund
Printed by authority of the State of Illinois. March 2014 — 500 — AR 9.10
I
ndividuals qualifying for a refund must sub-
mit requests within six months of date of
payment.
Any requests under $5 will not be refunded
per 15 ILCS 405 of the State Comptroller Act.
S
ecretary of State
D
epartment of Accounting Revenue
R
efund Section
222 Howlett Bldg.
Springfield, IL 62756
217-782-4908 (FAX) 217-557-4552
www.cyberdriveillinois.com
This space for use by Secretary of State
Accounting Revenue only.
F
ILE # _______________________________
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