Form Req16 - Motor Vehicle Plates/drivers Licence - Refund Request Form - Nova Scotia
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1PO Box 1652
Halifax, Nova Scotia
Motor Vehicle Plates/Drivers Licence
B3J 2Z3
Service Nova Scotia
Toll Free 1-800-898-7668
and Municipal Relations
Refund Request Form
Metro 902 424-5851
Fax 902 428-2180
Service Delivery
CLIENT IDENTIFICATION
(PLEASE PRINT ALL INFORMATION IN BLOCK LETTERS)
CLIENT(S) or COMPANY NAME
CLIENT MASTER NUMBER
DATE OF BIRTH
TELEPHONE NUMBER
DD
MM
YY
RESIDENCE ADDRESS
MAILING ADDRESS (If different than residence)
STREET NUMBER AND NAME, APT. NO.
STREET NUMBER AND NAME, PO BOX NO., RR. NO., APT. NO.
CITY, TOWN OR VILLAGE
POSTAL CODE
CITY, TOWN OR VILLAGE
POSTAL CODE
TYPE OF REFUND:
Licence Plate / Sticker - Plate No. __________________
Driver Licence
r
r
√
REASON: √
r
r
r
r
Sold
Left Province
Deceased
Repossession____________________
(Attach Proof of Death)
(Repossessor’s Name & Date)
r
r
r
r
Salvage (Junked)
Non-Repairable
Class Change
Vehicle Deleted from IRP Fleet
(Attach Damaged Vehicle Report)
(Attach Damaged Vehicle Report)
(New Class_____________)
(Date Removed from Fleet___________________________)
r
Change of Plate
r
Plate Not in Use
r
Medical/Physical or Non-Compliance of Demand
(Not Applicable for Commercial Plates)
(New Plate #_________________)
r
r
Stickers Returned
Other_________________________________________________________________
Date
_________________________________________________________
Signature of Applicant
D
D
M M
Y Y Y Y
If applying for a Licence Plate refund and you do not have the plate(s) to surrender, the plate owner must complete the Statutory
Declaration below.
STATUTORY DECLARATION
I, ______________________________________________, of the above stated address, do solemnly declare as follows:
First Name
Middle Name
Last Name
1. That I am the owner of the Vehicle Licence Plate(s) indicated above.
2. That the q plates were stolen and not recovered
Reported to ___________________________________
Police Agency
Date Stolen
Incident Report No. _____________________________
D
D
M M
Y Y Y Y
q plates were lost
Details ______________________________________
Date Lost
____________________________________________
D
D
M M
Y Y Y Y
q plates were demolished and unretrievable due to an accident
q Other _______________________________________________________________________________
3. That I will return the Vehicle Licence Plate(s) to the Registry of Motor Vehicles in the event they are recovered.
4. That I make this Solemn Declaration conscientiously believing it to be true and knowing that it is of the same and
effect as if made under oath by virtue of the Canada Evidence Act.
Declared before me at ________________________________ in the County of ________________________________.
City/Town
Province of Nova Scotia; this ___________________________ day of ___________________________, ___________.
Number
Month
Year
_______________________________________
_______________________________________
A Barrister or Commissioner of Oaths of the Supreme Court of Nova Scotia
Signature of Declarant
FOR INTERNAL USE ONLY - To be completed by RMV CSR
Plate Number
Accepted by (User Name)
Date
______________________
D
D
M M
Y Y Y Y
Driver licence surrendered
q Yes
q No
Class
Expiry
_______________________________
D
D
M M
Y Y Y Y
Refund
$
+ HST
$
_____________________ x _____________________ = ___________________ -
_______
=
___________________
Fee Paid
Total Months
Gross Amount
Refund Amount
Administration Fee
Form #REQ16 11/14
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