NOTICE AND DEMAND OF PAYMENT FOR MOTOR FUEL

Vehicle Owner

 

You are hereby notified that:

On __________, your vehicle with license plate number ____________* was observed

                  Date                                                                                             Plate Number

driving off without paying for $_________ of ___________________________________.

                                                                          Amount                                            Gasoline Type                                     

__________________________                            ______________________________

           Witnessing Employee Signature                                                                  Owner/Manager Signature

Text Box: AUTHORIZATION FOR DRIVER INFORMATION Company     Name_____________________________________________________________ Address_     __________________________________________________________________ City____     _______________________ State___________ Zip Code____________________ Phone__     ___________________________________Fax_____________________________ _______    _________________________________________________          ____/____/____ Signature    Signature of Owner/Manager                                                                         Date  

 

 

 

 

 

 

 

 

 

 

 


Remit $ ________  to _____________________________________________ by _______

                  Amount                                      Name and Address of Retailer                                                             Date                                                                                                    

The vehicle information being requested can be used only to demand payment for a “Drive-off”.

Any misuse, or publication of this information could lead to legal action.

 

There will be a $9.50 charge per license            Card Type _______________    

plate requested that is on file.  All plates

not on file, or that do not match your                 Acct :____________________ Exp ___/____

vehicle description will be at a charge of           

$5.50 per license plate.                                     Signature                                                          

Please fill out your credit card information

to the right.

                   Please check one                 ____MN   ____WI

                                                                                        ___Other

Please send the affidavit to vehicle owner and my location.                      Vehicle Description

                                                                                                            __________________

                                                                                                            __________________

DO NOT send affidavit, I am only requesting a plate look up.                                       

 

Fax this form to MSSA at 651-487-2447