Dulles Greenway Insufficient Funds Form

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Dulles Greenway Insufficient Funds Form 1-888-707-8870 (Toll Free)
INSTRUCTIONS: THIS FORM MUST BE FILLED OUT COMPLETELY AND MAILED WITH THE APPROPRIATE TOLL
TO 45305 CATALINA CT #102 STERLING, VA 20166 OR BROUGHT INTO OUR OFFICE IN ORDER TO AVOID
VIOLATION AND CITATION. YOU MUST INCLUDE YOUR VEHICLE’S LICENSE PLATE NUMBER AND/OR E-ZPASS
TRANSPONDER NUMBER.
DIRECTION
LICENSE PLATE NUMBER/ SMART TAG
DATE
TIME
LOCATION
TRANSPONDER
/
/
:
am/pm
Information in boxes above must be filled out completely and accurately to prevent citation procession.
MAKE CHECKS PAYABLE TO : DULLES GREENWAY
Name
Phone
Address
State
Zip
City
I acknowledge that I have passed through this toll facility without paying the required toll and agree to pay
the toll amount due within 48 hours. I understand that under Virginia code, failure to pay for services
rendered is punishable by a fine of not less than $100.
Signature

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