OFFICE OF THE SECRETARY OF STATE
DEPARTMENT OF ACCOUNTING REVENUE
SPRINGFIELD, ILLINOIS
The following SWORN STATEMENT is made by me to Jesse White, Secretary of State,
to support my request for refund of motor vehicle license fees.
That I am/was the owner of a _____________________________________________
____________________________ , VIN __________________________________
on which License No. _______________________ for the registration year _________
was issued by the Secretary of State.
The last date this vehicle was operated, while licensed and titled in Illinois in my name,
was on _________________________________ , and because of sale or non-use of
the vehicle, I am making a request to Jesse White, Secretary of State, for a refund of
the license fees of $ ____________ , paid by me.
I declare under penalty of perjury under the laws of the State of Illinois that the state-
ments above are true and correct.
____________________________________
____________________________________
____________________________________
Printed by authority of the State of Illinois. March 2013 — 100 — AR 14.10
Signature
Address
(Month/Day/Year)
(Month/Day/Year)
