Affidavit Of Non-Liability / Contested Notice Of Toll Evasion Page 3
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1
2
3Violation Details
Violation
Toll
License Plate
Make
Plaza
Lane
Date
Time
Penalties
Total
Number
Amount
T12120
4-0001 NV
GGB
07
12/13/12
14:01
$6.00
$25.00
$31.00
Returned Check Fee:
$0.00
Total Amount Due before 04/26/2013:
$31.00
Delinquent Penalty ($45 per Violation):
$45.00
Total Amount Due after 04/26/2013:
$76.00
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PLEASE DETACH THIS PORTION AND RETURN IT WITH YOUR PAYMENT
Violation Processing Department
*T1212015504*
PO Box 26925, San Francisco, CA 94126
04112013051120131212015504003100
877-BAY-TOLL (877-229-8655) TDD/TTY 1-415-486-2492
Fax 1-415-956-1663
TEV# T12120
Notice Date: 04/11/2013
Amount Due: $31.00
Due Date: 05/11/2013
If paying by credit card, please provide the information below. We accept VISA, AMEX, Discover, MasterCard.
Credit Card No.:__________________________________________Expiration Date:__________/__________
Print Name:______________________________ Phone:(_____)__________Email:______________________________
Signature:______________________________________________________Date:______________________________
Check / Money Order (Make Checks Payable to FasTrak Violation Processing Department and use the Courtesy Reply Envelope)
NOTE: YOU CAN ALSO PAY IN FULL 24/7 USING A CREDIT CARD BY CALLING 1-877-BAY-TOLL OR VISITING
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