Creamery Building, 21 S Kent Street, Suite 100, Winchester, VA 22601 Telephone: (540) 667-1815
Email: cor@winchesterva.gov FAX: (540) 667-8937
Website: www.winchesterva.gov
High Mileage Application – Passenger Vehicle
Tax Year: ______________________ Bill Due Date: _____________________________
Account Number: _________________ Item Number: _____________________________
Owner Name: ________________________________________________________________
Address: ____________________________________________________________________
Telephone: __________________________________________________________________
Vehicle Year: ____________________ VIN: ____________________________________
Vehicle Make and Model: _______________________________________________________
Mileage for Tax Year: __________________________________________________________
Required Documentation:
Documents should be dated as near as possible to the start of the vehicle’s twelve-month billing
cycle during that tax year. For example: If the application is for your 2020 Tax Year and the bill
due date is June 30, 2021, your documentation should be dated as close as possible to June,
2020.
You must attach a copy of one of the following for this vehicle during the appropriate tax year.
• Unaltered inspection receipt
• Oil change or service repair receipt from a vehicle care center or service station
• Odometer certification certificate
• Title, if issued for the above tax year
To receive any applicable high mileage discount, you must submit this documentation no later
than the bill payment due date for the above tax year. Applications received without proper
documentation will not be accepted.
Certification of Owner:
I declare, under penalty of perjury, that the information provided is complete, true and correct to
the best of my knowledge and that I am the owner or other person specifically authorized in
writing to sign.
Signature: _______________________________ Date: _______________________________
Printed Name: ________________________________________________________________
