Appeal Form
Notice Account Violation Date/Time: PIazafLane:

Instructions:
Visit our website if you are an E-ZPass account holder or wish to pay the Total Amoum Due by credit card.

You may also pay your Violation by telephone using a credit card. Dial 1-877-877-5882; press 1 for the E?ZPass Customer Service CenterNioIations
Processing; press 3 because you received a Violation Notice; press 1 if you wish to make a payment; press I again to make the payment. Follow the
prompts to process your payment.

For year appeal to be considered, you must complete the following steps within thirty (30) days of receipt of this notice:
Complete Seetion A, B, or of the appeal form below.
Sign and date the certification at the bottom of the appeal form.

Mail this appeal form direct to:
  Ill

Violation Processing Center

8000C Derry Street

Harrisburg, PA 17111
If review of appeal form Section shows that you were an E-ZPass Customer in good standing on the relevant date, the Toll Balance Due will be
deducted from your E-ZPass account. In all other cases, the results of the review will be mailed to you. If you require further information, call
1-877-877-5882.



 

Section A certification of Non-Liability
The undersigned certi?es that on the date of the violation the vehicle bearing the registration plate number on the Violation Notice was (check
one only):

'3 Stolen El Leased or Rented to another person Other - Written Appeal. See attached statement.
LesscefRenter Information:

 

 

 

 

 

Name Driver's License Number
Address

City State Zip Code
Phone Number Date of theft or execution of lease agreement

Note: In order to assert either of these defenses, you must provide the following documentation:

If you allege that your vehicle was stolen at the time of the violation, you must provide a copy of the police report (if available) or law
enforcement agency name, incident number, and date stolen.

- If the vehicle was leased or rented, you must provide a copy of the lease or rental agreement or other such contract covering the vehicle on the
date of the violation with the name, address, and driver's license number of the lessee or renter, clearly legible by the appeal due date
speci?ed on the violation notice.

Failure to send such information by the appeal due date will render the owner, lessor, or rental agent liable for the total amount due.

Section B: Overcoming Inference of Owner Liability
The owner of the vehicle is inferred to be the operator at the time of the violation. In order to overcome the inference, the vehicle owner must provide
the following information:

Testimony/statement that the owner was not operating the vehicle at the time of the violation.

indicating thename and residence addressof operating the vehicle at the time of the violation.

 

Section C: E-ZPoss Customer Verification
I hereby certify that I was an E-ZPass customer in good standing and had a valid E-ZPass tranSponder in the vehicle at the time of the alleged violation.
Enclosed is my most recent account statement that shows my name, address, transponder number and that I have a positive account balance.

 

Name of E-ZPass Account Holder E-ZPass Account Number

 

 

Signature of E-ZPass Account Holder Phone Number



 

Transponder Number (above the barcode 0n the transponder)

 

Certi?cation: To be completed for all Appeal orrn Sections.

I certify that the foregoing statements are true and accurate to the best of my knowledge. I understand that if any of the foregoing statements are
will?illy false, I am subject to penalties pursuant to Law.

 

Signature Print Name Date