Account Transfer Worksheet - Massachusetts Department Of Transportation printable pdf download

Account Transfer Worksheet - Massachusetts Department Of Transportation

E-ZPass MA Customer Service Center

27 Midstate Drive

Auburn, Massachusetts 01501-1839

1-877-627-7745

1-508-786-5222 (Fax)

ACCOUNT TRANSFER WORKSHEET

→ Both parties must complete and sign this form. If opening a new account, please return this

form attached to a new account application completed and signed by the new

account/transponder owner.

CURRENT OWNER OF TRANSPONDER:

I, ___________________________, authorize E-ZPass MA to transfer ownership of the following:

1. Transponder # _______________________ Transponder # ___________________________

Transponder # _______________________ Transponder # ___________________________

2. I authorize the transfer of this/these vehicles to the new owner’s account (leave blank if not

transferring any vehicles).

License Plate

State

Plate Type

Make

Model

Year

1. _________________ ______ ___________ _________________ ________________ ________

2. _________________ ______ ___________ _________________ ________________ ________

3. _________________ ______ ___________ _________________ ________________ ________

3. I would like to close my existing E-ZPass MA account.

(Please circle one)

IF you are closing your account, please check ONE of the following:

____ I would like a refund of the remaining balance.

____ I authorize E-ZPass MA to transfer the remaining balance to the new account holder.

Signature: __________________________________

Date: ____-______-______

NEW OWNER OF TRANSPONDER:

I, _____________________________________, accept responsibility of the above.

Signature: __________________________________

Date: _____-______-_____

_____ I have an existing E-ZPass MA account in my name, Account # ___________. (If you do

not currently have an E-ZPass MA account, you must complete a new account application).

_____ I am opening a new E-ZPass MA account. (Please send in this completed Account Transfer

Worksheet and a completed new account application).

If there are any questions, please call E-ZPass MA Customer Service at 1-877-627-7745.

E-ZPass MA use only: Transferred from Account #_______________ to Account # ________________

Clerk Init: ___________ Date: ______-______-______

08/12

Account Transfer Worksheet - Massachusetts Department Of Transportation