Change Of Information Form - Massachusetts Department Of Transportation printable pdf download

Change Of Information Form - 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)

CHANGE OF INFORMATION FORM

E-ZPASS MA ACCOUNT NUMBER: _____________________________________

I, __________________________________________, would like to change my…

Section A – Credit/Debit Card Information:

To:

Credit/Debit Card #: _____________________________________ Exp. Date: ___ - ____ -____

Note: If you previously had Checking Account Information listed on your account, DO NOT use this form. Please submit an Option Change Form.

Section B – Checking Account Information:

To:

Routing#: ____________________

Account #: ___________________________________

Note: If you previously had Credit / Debit Card Information listed on your account, DO NOT use this form. Please submit an Option Change Form.

Section C – NEW Address, Telephone(s) or Email address:

Street Address: ________________________________________________________

City: ___________________________ State: __________

Zip Code: ____________

Home Telephone: (____) ______________ Business Telephone: (____) _____________ Ext_______

Cell Phone:

(____) _______________ Fax:

(____) ________________________

Email address: _________________________________________________

Section D – User

I would like to add ______________________________ to my E-ZPASS MA account as an authorized contact person.

(Print First and Last Name)

Section E – PIN (4-digit number)

I would like to change my PIN code to: _____ _____ _____ _____ (4-digit number)

Section F – Vehicle Information changes (please circle either change or add or delete):

PLEASE NOTE: If you are participating in either the Tunnel Communities or Tobin Resident Program, you must bring a

copy of your vehicle registration to the E-ZPass Customer Service Center located at 145 Havre Street, East Boston, MA

02128.

I would like to change/add/delete my vehicle information to: Do you need extra fastener strips? yes no

NOTE: If you need an additional transponder for any vehicle listed below, please contact the E-ZPass MA Customer

Service Center.

Plate#_____________State_____Plate Type_____Make ________________Model _______________Year _____

I authorize the change of information on my account as indicated above, and certify that all information contained on this

form is true and accurate.

Signature:____________________________________________Date:______-______-______

08/12

Change Of Information Form - Massachusetts Department Of Transportation