HSMV 73644 (Rev 07/11)
Division of Motorist Services
Refund Request
A refund is requested for the Following (Check proper box/boxes)
License Fee Examination Fee Service Fee
FR Re-fee ID Card Fee Other ________________________
List All Applications Pertaining to Refund Below:
Date (s) Applied __________ Office # __________ Audit # (s) __________ Fees Paid __________
____ ______ __________ __________ __________
____ ______ __________ __________ __________
Justification for Refund (Explain Fully):
Name
Address
Driver License Number
Date of Birth Total Refund Office
ID
Examiner ID
Date
Customer’s Signature
Instructions: Please complete, print and sign this form.
Mail form to:
Division of Motorist Services
P.O. Box 5775
Tallahassee, FL 32314-5775
