Affidavit Of Non-Liability / Contested Notice Of Toll Evasion (Page 2 of 3) in pdf

Affidavit of Non-Liability / Contested Notice of Toll Evasion

TEV#: T12120

Pursuant to California Vehicle Code (CVC) Sections 40250 and 40254, the registered owner of the vehicle is responsible for all toll evasion violations

committed by that vehicle. If you do not agree that you owe the amount shown on the front of this notice, if you do not own or have not rented the vehicle

listed, or if you are a Bay Area FasTrak or License Plate account holder, you have fifteen (15) days from the notice date to complete and return this form to

the FasTrak Customer Service Center.

Complete Only One of the following Sections A, B or C.

Section A: AFFIDAVIT OF NON-LIABILITY

The undersigned declares that the vehicle bearing the license plate on the Notice of Toll Evasion was not owned by me/was rented to another party on

the date of the violation. The vehicle was (check one only):

SOLD or TRANSFERRED

LEASED or RENTED

TRAILER or CONTAINER

REPORTED STOLEN

Name and Address of Responsible party is:

Name: _______________________________________________________

Address: ___________________________________ City: _____________________State: ___________ ZIP Code: __________

Date of sale, theft or execution of rental/lease agreement:_________________________________

I declare under penalty of perjury that the foregoing is true and correct:

Signature:_____________________________ Date: _________________ Phone: ( ______ )_________________

One of the following must accompany this Affidavit as acceptable proof of non-liability: (1) declaration of non-ownership, (2) a copy of the bill of

sale or release of liability filed with the DMV, (3) a copy of the lease or rental agreement providing the rentee/lessee information and term of

agreement, (4) a police report citing the date of theft. Failure to provide or accurately complete the above information, as well as lack of verification

of such by DMV, will result in this Affidavit being disregarded.

Section B: CONTESTED NOTICE OF TOLL EVASION

I do not believe I owe the amount shown on the reverse side of this notice. I am requesting an investigation of the items which constitute my defense

against liability of the violation. I have attached a written explanation of the reasons I am contesting the violation.

Print Name: ___________________________________________ Phone: ( _____ ) _______________________________

Signature: ____________________________________________ Date: ________________________________________

You will be notified of the investigation results by mail. If you are not satisfied with the results, you may request an administrative review within 15

days from the mailing date of the results, after depositing the amount due pursuant to procedures set forth in California Vehicle Code Sections 40255

and 40256.

Section C: FASTRAK OR LICENSE PLATE ACCOUNT CUSTOMER

FasTrak Account:

I am a Bay Area FasTrak account holder in good standing and had a valid transponder in the vehicle at the time of the violation

shown on this notice. Please charge my account for the toll amount only. I understand I am liable for the full amount due shown on this notice if my

account does not have a sufficient balance and/or the transponder was not in a valid status at the time of the violation. Failure to completely and

accurately provide the information below will result in this declaration being rejected.

To prevent violation(s), I authorize FasTrak to add to my account the following license plate: NV

License Plate Account:

I am a License Plate account holder in good standing at the time of the violation shown on this notice. Please charge my

account for the toll amount only. I understand I am liable for the full amount due shown on this notice if my account does not have a valid credit card

on file or a sufficient balance at the time of the violation. Failure to completely and accurately provide the information below will result in this

declaration being rejected.

To prevent violation(s), I authorize Pay-by-Plate to add to my account the following license plate: NV

I have been responsible for this vehicle since_________________________________Account Number: ________________________________

Account Holder Name:_______________________Signature:____________________Transponder Number (if FasTrak):____________________

If you are a FasTrak account holder from a different toll agency, you may do ONE of the following:

•

Update your vehicle information with your local FasTrak Customer Service Center within 10 days of this notice. This violation will continue to

escalate until resolved. OR

•

Dispute the violation using Section B above. OR

•

Pay this violation online at

Questions about your Violation Notice?

Please call (877) BAY-TOLL (1-877-229-8655) or (1-415-486-8655), 8:30am-5:30pm, Mon-Fri and 9:00am-1:00pm Sat. Fax #: 415-956-1663

FasTrak Violation Processing Department, PO Box 26925, San Francisco, CA 94126. Visit us on the web at:

*T1212015504*

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Affidavit Of Non-Liability / Contested Notice Of Toll Evasion Page 2

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