Non Standard Settlement Request Form PDF Details

Navigating financial obligations with tollway authorities can become a complex process, especially when facing financial hardship. The Non-Standard Settlement Request form emerges as a crucial tool for individuals who find themselves struggling to meet their toll-related financial responsibilities. This form allows violators to detail their financial situation comprehensively, covering aspects from basic personal information, including the violator's name, address, and contact details, to more in-depth financial data like household income, assets, liabilities, and any previous payments towards the owed amount. It also provides space for the violator to explain the reasons behind their toll violations and any hardships that might impede their ability to pay the standard fines. This explanation is pivotal as it offers a human element to the financial record, giving the authorities a fuller picture of the violator’s situation. The involvement of financial details such as bank accounts, property ownership, and monthly expenditures underlines the seriousness with which this form approaches the settlement process. By attaching necessary documents, such as pay records and tax returns, the violator supports their claim for a customized settlement plan. Furthermore, the form includes a section for proposed settlement amounts and the source of these funds, which is then subject to approval by tollway authorities. The explicit requirement for honesty and the legal declaration at the form's conclusion highlight the form's legal implications. This document provides a structured pathway for individuals to negotiate their toll payments, underlining the importance of transparency and documentation in the process of financial negotiation.

QuestionAnswer
Form NameNon Standard Settlement Request Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesillinois tollway form, illinois tollway hardship, ipass violation relief, settlement request

Form Preview Example

Non-Standard Settlement Request

Violator’s Name: ________________________________________________Phone #:_________________________

Address: __________________________________ City, State Zip: ______________________________________

License Plate(s): ____________________________ I-Pass: Yes or No (Circle) If yes, I-PASS Account #:

Hearing Date: ______________________________

Total number of persons in household: _________

Amount owed:

TOTAL: $ ___________ Amount Previously Paid $ ____________

 

Tolls $ ________ Pre-escalation fines: $ _________ Escalated Fines: $ __________

Reason for Violations/Hardship: ____________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

Bankruptcy: Yes or No (Circle) If YES, Case #: _______________.

Subject to Stay: Yes or No (Circle)

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

Spouse/Family Member/Household Member Monthly Income $ _____________ (Attach copy of pay record)

Assets: Total: $ _________________

 

 

-Checking/Saving Accounts:

Total$____________________ (Attach copy)

-House: OWN or RENT (Circle)

Value $ _____________

Owe: $ ____________________________

-Car

Value $_____________

Owe $_____________________________

Liabilities: Total: $ _________________

-Monthly Expenses:

 

Housing: $___________

Car: $ __________ Electricity: $ __________ Gas $ __________

Other Expenses:

-Medical: $ __________. (Attach documentation of invoices if to be considered)

Violator’s Proposed Settlement: $ ____________

Source of Funds: (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.

Signature: ______________________________________________________________ Date: _______________

Mail completed form with supporting documents to: Illinois Tollway, Customer Service Center, 2700 Ogden Ave., Downers Grove, IL 60515

To be completed by Tollway

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

Assistant Attorney General: _______________________ Approved: YES or NO (Circle) Amount: $_____________

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illinois tollway payment plan request conclusion process explained (portion 2)

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Assistant Attorney General, Tollways Settlement Offer, and To be completed by Tollway of illinois tollway payment plan request

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