Application For A Refund Of The Tax Paid On A Motor Vehicle Leased By A Veteran (PDF)

Application For A Refund Of The Tax Paid On A Motor Vehicle Leased By A Veteran Or A Veteran’s 
 Survivor(s) Eligible For Property Tax Exemptions Under CGS §12-81(19), (20), (21), (22), (23), (24), (25) or (26) 
 
This form must be completed and returned to the assessor of the town that taxed the vehicle described below, not later than the thirty-
first day of December next following the assessment year during which such tax was paid. The assessor may require you to submit 
motor vehicle lease verification information. Failure to file by the deadline constitutes a waiver of the right to claim a refund under §12-
93a(b). Only the town that received the tax payment on the vehicle can issue a refund. If you are not a resident of that town, you must 
file this application with the assessor of the town that taxed the vehicle, and you must have filed a nonresident affidavit with the 
assessor of that town under the provisions of §12-94. 
 
Claimant Information 
 
1. 
Claimant’s name: 
 
2. 
Name of claimant’s spouse: 
 
 
3. 
Claimant’s address: 
 
 
 
 
 
 
 
Number & Street 
 
City or Town 
 
State & Zip Code 
4. 
This claim is submitted for the assessment date of October 1,  
 
. 
 
5. 
Vehicle Registration (Plate) Number: 
 
Make, Model and Year: 
 
 
6. 
Leased From: 
 
To: 
 
Lessor: 
 
(Mo/Date/Yr) 
 
(Mo/Date/Yr) 
 
(Name of vehicle owner as it appears on lease) 
 
7. 
Lessor Address: 
 
 
 
 
 
Number & Street or PO Box 
 
City or Town 
 
State & Zip Code 
 
8. 
Leased to: 
 
8. 
Relationship to claimant 
 
 
 
 
(Self, Spouse, and etc.) 
 
9. 
If lessee is spouse of claimant, do spouse and claimant reside together? 
Yes   
No   
 
 
10. 
Has there been a change to vehicle since assessment date? 
Yes   
No   
If Yes, explain. 
 
 
Attestation Statement 
 
I hereby do hereby apply for a refund of the tax paid for the leased motor vehicle described above, pursuant to §12-93(b) and based 
upon my eligibility for an exemption under §12-81(19), (20), (21), (22), (23), (24), (25) or (26) as of the assessment date. All 
information herein provided is true and accurate to the best of my knowledge and belief.  
 
 
 
 
 
 
 
 
 
Signature of Claimant 
 
Date 
 
 
 
For Municipal Use Only – Calculation and Certification Of Tax Refund For A Leased Vehicle 
 
Regular Grand List  
Supplemental Grand List  
Vehicle Assessment: 
$ 
 
 
Town  
Lesser Taxing District  
 
                             District Name 
 
Exemption 
  Balance: 
 
$ 
 
X  Town Mill Rate 
= Available Benefit: 
 
$ 
 
X  District Mill Rate 
= Available Benefit: 
 
$ 
 
 
Amount of Town Tax: 
$ 
 
Amount of District Tax 
$ 
 
            
 
                   Assessment  X  Town Mill Rate 
 
 
                               Assessment  X  District Mill Rate 
 
Town Refund Amount: 
$  
District Refund Amount: 
$  
 
Refund Amount: Enter available benefit, if less than amount of tax. Otherwise enter amount of tax. 
 
 
Refund Approved  
Denied  
Reason for denial: 
 
 
 
 
 
Signature of Assessor and Date Signed 
Certification of refund amount(s) 
 
Signature of Tax Collector/District Clerk and Date Signed 
Certification that vehicle tax has been paid