* 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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What is this file, what does it show?
Attachment 2
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