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S Requesting a Refund Date Street Address City State Customer #1 ID Number (from original payment receipt) Zip Code Social Security # (if Individual & payment made to DOR) Daytime Telephone Number Driver s License # & State of Issue (if Individual & payment made to County Tag Office) EIN (Employer ID # if business) B. Vehicle Information Vehicle Year C. Vehicle Make Current Tag Number Vehicle ID Number/Manufacturer s ID Number I request a refund of the following fee paid directly.

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