* indicates the field is mandatory
Surname *
Given name/s *
Postal address
Please provide at least one way that we can contact you if required.
Email address *
Phone number
Mobile number
Note: If you are applying for a refund due to a change of status (e.g. you are now entitled to a concession as a pensioner or association member), please complete the form to update your dog registration details first.
What does the refund relate to? *
Reference number
(i.e. Dog tag number, Rate assessment number, Licence number, Application number)
Reason for refund request: *
When was the payment made? *
Amount requested to be refunded?
Note: If the payment was made by Bpay, please contact your financial institution to initiate a Bpay recall
*
Method of payment?
Receipt number?
Provide any additional details or further information
If you have any documentation or supporting evidence, please attach it below. Please limit attachments to 20MB.
Attachment 1
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Attachment 2
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