Non-Standard Settlement Request Form - State Of Illinois printable pdf download

Non-Standard Settlement Request

Please complete application thoroughly. Incomplete applications are subject to denial.

Violator’s Name: _________________________________ License Plate(s): __________________________

Violator’s Address: _______________________________ City, State Zip: _________________________

Violator’s Telephone Number: ______________________ Total number of persons in household: _________

Amount owed: TOTAL: $ __________ Amount Previously Paid $ _________

Do you have an IPASS account? ________ If yes, what is the account number? _____________________

Why did the violations occur? _________________________________________________________________

What is the reason a hardship/payment plan is needed? _____________________________________________

Have you filed bankruptcy? _____ If yes, Case # _______________.

Subject to Stay: Yes or No

Violator’s Monthly Income: $ _____________ (Attach copy of pay record or Federal tax return)

Spouse/Family Member/Household Member or Government Benefits Monthly Income $ _____________

Assets: Total: $ _________________

-Checking/Saving Accounts: $____________________ (Attach copy – NOT originals)

-House (Circle: Own or Rent) Value $ _____________ Owe: $ ___________

-Car Value $___________ Owe $___________

Liabilities: Total: $ _________________ (Do not attach originals)

-Monthly Expenses:

Housing: $___________

Car: $ __________ Electricity: $ __________ Gas $ __________

Other Expenses: _________________ $ ____________; ___________________ $ _________________

-Medical: $ __________.

Violator’s Proposed Settlement:

How much can you pay each month? __________

OR How much can you pay within 60 days? ________

Please do not enter $0; if no payment amount is listed or satisfactory, an amount will be determined for you.

How will this amount be paid? (savings, credit card, or borrowed from third party) _________________

Under penalties of law, I declare that I have examined this return and accompanying schedules and statements, and to the best of my

knowledge and belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of

which preparer has any knowledge.

Violator’s Signature ______________________________________ Date: _______________

Illinois Tollway: Attention Customer Service

Mail COMPLETED application with supporting documentation to:

2700 Ogden Avenue

Downers Grove, IL 60515

To be completed by Tollway

Tollway’s Settlement Offer: $ ___________ Recommending Supervisor: ____________________________

Assistant Attorney General: _______________________ Approved: Yes or No – Amount $_____________

Non-Standard Settlement Request Form - State Of Illinois