STATE OF INDIANA

Michael R. Pence, Governor

Donald M. Snemis, Commissioner Mike Alley, Commissioner
Bureau of Motor Vehicles Department of Revenue
888-692-6841




Date

Customer Name
Customer Address
Customer Address 2
City, State, Zip

Dear BMV Customer:

The Indiana Bureau of Motor Vehicles has determined that a vehicle you currently own, or a vehicle you
owned in the past, was misclassified for excise tax purposes. As a result, we believe that you overpaid
motor vehicle excise taxes. The vehicles affected and the amount of the overpayment is shown on the
Application for Excise Tax Refund. Simple interest will be applied at the time of the refund according to
standard Indiana Department of Revenue interest rates, as follows:

Year Interest Rate Year Interest Rate
2004 2% 2009 7%
2005 1% 2010 4%
2006 2% 2011 9%
2007 (January 1 to June 30) 3% 2012 4%
2007 (July 1 to December 31) 5% 2013 3%
2008 7% 2014 3%

If the registrant is deceased, the survivor or distributee must complete the Survivors or Distributees of
Decedents Section of the form.

In order to receive this refund, please complete the enclosed claim form, sign it and return it in the
enclosed self-addressed envelope.

The BMV deeply regrets this error and any inconvenience it may have caused.













APPLICATION FOR VEHICLE EXCISE TAX REFUND
State Form 55677 (9
Approved by State Board of Accounts, 2014
INDIANA BUREAU OF MOTOR VEHICLES

INSTRUCTIONS:

1. Complete in blue or black ink or print form.
2. Print the mailing address you wish the refund check to be mailed to.
3. Mail in the required proof with this application. If you are signing on behalf of the reg
photocopy of document that authorizes you to do so (I.E., POA, Executor)
4. If registration has more than one (1) registrant, the primary registrant must c
5. Mail this application and all required additional documentation to the address listed at the top of this form.
6. Applicable refund check will be mailed payable to the Applicant at the address indicated below.
SECTION 1: REGISTRANT
Registrant's Name
Preprinted field
Mailing Address (street number and name)
City
Contact Telephone Number
( )
SECTION 2: VEHICLE INFORMATION
Vehicle Year, Make, Model
Preprinted field









SECTION 3: APPLICANT AFFIRMATION
I swear or affirm under penalty of perjury that I am requesting a refund of
a refund has not been previously issued for this vehicle. I confirm that the
I request the BMV mail the refund check to.
Signature of Applicant
Printed Name of Applicant

SURVIVORS or DISTRIBUTEES OF DECEDENTS SECTION


APPLICATION FOR VEHICLE EXCISE TAX REFUND
(9-14)
Approved by State Board of Accounts, 2014
INDIANA BUREAU OF MOTOR VEHICLES
Winchester Processing Center
1. Complete in blue or black ink or print form.
the mailing address you wish the refund check to be mailed to.
3. Mail in the required proof with this application. If you are signing on behalf of the reg
photocopy of document that authorizes you to do so (I.E., POA, Executor)
4. If registration has more than one (1) registrant, the primary registrant must complete this form.
5. Mail this application and all required additional documentation to the address listed at the top of this form.
6. Applicable refund check will be mailed payable to the Applicant at the address indicated below.
SECTION 1: REGISTRANT INFORMATION
State
Email Address
SECTION 2: VEHICLE INFORMATION
Years Affected
Preprinted field
Principal Refund Amount
Preprinted field









SECTION 3: APPLICANT AFFIRMATION
I swear or affirm under penalty of perjury that I am requesting a refund of Excise Tax and/or Surtax on the vehicle listed above and that
his vehicle. I confirm that the above mailing address is correct and that this is the address
Date Signed (mm/dd/yyyy) Last 4 digits of Applicant's SSN/FIN
Relationship to Registrant(s) (if other than registrant)
(Example: agent, POA, executor of estate, etc.)
Total refund for vehicle
misclassification
(excluding simple interest)
Preprinted field
SURVIVORS or DISTRIBUTEES OF DECEDENTS SECTION
Bureau of Motor Vehicles
Winchester Processing Center
PO Box 100
Winchester, IN 47394
888-692-6841
the mailing address you wish the refund check to be mailed to.
3. Mail in the required proof with this application. If you are signing on behalf of the registrant, you must provide a
photocopy of document that authorizes you to do so (I.E., POA, Executor)
omplete this form.
5. Mail this application and all required additional documentation to the address listed at the top of this form.
6. Applicable refund check will be mailed payable to the Applicant at the address indicated below.
State ZIP Code
Principal Refund Amount
Preprinted field









vehicle listed above and that
above mailing address is correct and that this is the address
Last 4 digits of Applicant's SSN/FIN
Total refund for vehicle
misclassification
(excluding simple interest)
Preprinted field


* This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is voluntary and you will not be penalized for refusal.
This form applies only to Survivors or Distributees of Decedents. Survivors or Distributees may obtain the Decedent's refund in the form of a
check mailed by the BMV by completing the following information.
SECTION 1: DECEDENT INFORMATION
Decedent's Name (as printed on Indiana driver's license or identification card)
Preprinted field
DRIVER'S LICENSE NUMBER or SOCIAL SECURITY NUMBER: (Please enter in spaces below.)
Please indicate if the following is the Decedent's: or
Indiana Driver's license or Identification card number Social Security Number *
(Please enter in spaces below.)


SECTION 2: APPLICANT INFORMATION
Please check which of the following applies:
Survivor

Applicant affirms that:
1. No petition for the appointment of a personal representative for the estate of the decedent is pending or has
been granted.
2. Forty-five (45) days have elapsed since the death of the decedent.
3. They are entitled to receive said monies either by will of the decedent or statute.
Distributee

Applicant affirms that:

1. Decedent left no widow or widower surviving him or her.


2. No petition for the appointment of a personal representative for the estate of the decedent is pending or has
been granted.

3. Forty-five (45) days have elapsed since the death of the decedent.


4. They are entitled to receive said monies either by will of the decedent or statute.

Mailing Address (street number and name)
City State ZIP Code
Contact Telephone Number
( )
Email Address
SECTION 3: APPLICANT AFFIRMATION
I swear or affirm under penalty of perjury that I am requesting a refund for the decedent above; that a refund has not been previously
issued for this individual; and that all the information contained in this form is correct. I confirm that the above mailing address is
correct and that this is the address I request the BMV mail the refund check to payable in my name.
Signature of Applicant Date Signed (mm/dd/yyyy)
Printed Name of Applicant Relationship to Applicant(s) (if other than Applicant)
(Example: agent, POA, executor of estate, etc.)
SECTION 4: NOTARY
Subscribed and sworn before me, a Notary Public, this ____________ day of ______________________, ____________.
Signature of Notary Public

My Commission Expires (mm/dd/yyyy)

Printed Name of Notary Public Resident of (County/State)