Leavenworth County Treasurer 				           Motor Vehicle Property Tax (Due/Credit/Refund)
300 Walnut Ste 105						Motor Vehicle Refunds (Completed by County)
Leavenworth KS 66048					County Treasurer Relinquished Plate Collection Certification
			    				  All Refunds Except "R", "P" or "L" VIPS System Refunds
									REQUIRED FOR REFUND
County Number:______052________		
County Name: ___Leavenworth____            	        Customer Social Security Number:    _________________
Application Date:_______________		                               or
							Federal Tax ID Number:________________________

Plate Number __________  Registration Type:  Reg__  PN__ NG__ DS__ AR__ EX__ SI__ SR__ AN__ DV__ KS__ HP__

Vehicle Type:  AU___ LT__ HT__ MC__ MB__ MH__ TR__ AT__ SS__ ELEC__     VIN:   ___________________________

Refund Code:  Property Tax ______  Registration _____ Title Fee _____ Personalized Plate _____
                      Vehicle Make _________ Year ________ Gross Wt. _______ Reg Year ________  Tax Unit ________

Owners Name (Last, First, MI)
_____________________________________________________________________________________________
Street, City, State, Zip Code
_____________________________________________________________________________________________
A. 	Property Tax Refund/Credit/Due (completed by County Appraiser/Clerk) 
	NO REPLACEMENT VEHICLE REFUND
	1.   $___________________ Full Year Property Tax Amount
	2.   $___________________ Monthly Property Tax (line 1 divided by 12 months)
	3.   $___________________ Number of full months remaining in registration period
	4.   $___________________ REFUND (multiply line 2 by line 3)
	REPLACEMENT VEHICLE REFUND
	1.   $___________________ Full Year Property Tax Amount (on vehicle replaced)
	2.   $___________________ Monthly Property Tax (line 1 divided by 12 months)
	3.   $___________________ Number of full months remaining in registration period
	4.   $___________________ Credit (multiply line 2 by line 3)
	5.   $___________________ Full Year Property Tax due (on replacement vehicle)
	6.   $___________________ Monthly Property Tax (line 5 divided by 12 months)
	7.   $___________________ Number of full months remaining in registration period
	8.   $___________________ Tax Due (multiply line 5 by line 7)
	9.   $___________________ REFUND (amount by which line 4 exceeds line 8)
	10. $___________________ TAX DUE (amount by which line 8 exceeds line 4)

B.	Vehicle Registration Refund:  Quarterly Pay Cancellation or Refund __________________________________
	Basis for Refund:	Vehicle was Sold _____ Junked _____Repossessed_______ 
				Renewed Twice_____ Renewed in Error_____ Owner Deceased_____ Date__________
	1.    Explanation for Refund:___________________________________________
	2.    Number of Full Months Remaining in Registration Period _______________
	3.    Registration Amount $_______  County Paid Registration Fees: YES____ NO____ (less $5.00 County Service Fee)

C.	Title Fee Refund_______ Personalized Plate Refund_______ Over Charge of Fees or Penalties_________
	1.    Explanation for Refund:____________________________________________
	2.    Refund Amount $____________                      County Paid  YES____ NO____

OWNERS CERTIFICATION: I, the owner of the above described vehicle hereby	              TOTAL REFUND   $ ________
make application for refund. I hereby swear and affirm that the above information		PROPERTY TAX   $________
is true and correct. If vehicle was not replaced I hereby relinquish the registration		VEHICLE REG      $________
plate assigned and forfeit the right to register another vehicle under this plate number.

Owners Signature:______________________________________________________  Date:_____________
I, the undersigned County Treasurer, certify as the above reference license plate(s) and registration receipt have been
surrendered for cancellation to the County Treasurer on this date:_____________________

County_ ____________________________    Treasurer's Signature___________________________________