For Office Use Onl
Date Received
Case #
Code
FasTrak® Customer Service Center
P.O. Box 26925
San Fr
ancisco, CA 94126
www.bayareafastrak.org
Phone 1-877-BAY-TOLL (1-877-229-8655)
Fax 1-415-974-6356
DMV Registration Hold Request for Review Form
INSTRUCTIONS: If there was a hold placed on your DMV vehicle registration due to unpaid toll violations, you
may request a review of your dispute by completing this form (use a separate form for each license plate number).
Fill in the information requested, print it out, and send it to the address above. To expedite your request, please
include a copy of your current DMV registration, DMV registration renewal, and/or documentation of violations
already paid directly at the DMV. Within 15 business days from submittal of this form, a letter will be sent to you
with the required payment amount due from you, along with a list of all unpaid violations.
IMPORTANT: Submittal of this Request for Review Form will not: 1) release the current hold on your DMV
vehicle registration; 2) stop the process of additional violations being sent to DMV Hold and/or Collections; or
3)
recall violations which have already been sent to Collections.
REGISTERED VEHICLE OWNER INFORMATION:
Last Name, First Name Vehicle License Plate Number
Current Mailing Address State of Registration
City, State, Postal Code Current FasTrak Account Number, if any
Contact Phone number(s) Previous FasTrak Account Number, if any
VIOLATION NUMBER(S): (IF MORE SPACE IS NEEDED, ATTACH
ADDITIONAL SHEETS.)
Written Dispute: (If more space is needed, attach ad
ditional sheets.)
Print Name Signature Date
