Fillable FORM 33-11B: Pennsylvania Turnpike Commission

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FORM 33-11B: Pennsylvania Turnpike Commission

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FORM 33-11B
E-ZPass Customer Claim Report
Pennsylvania Turnpike Commission
Your account may have been charged the maximum fare. In order to be considered for an
account adjustment, you must complete and return this form within 45 days from the date of
transaction with a ticket and/or receipt and a copy of your statement. INCOMPLETE
REQUESTS WILL
BE REJECTED AND RETURNED!
Return to: PTC E-ZPass Customer Service Center
Harrisburg, PA 17111
❏
Returning Unused Ticket
❏
Contest a Toll Charge
❏
Other
Please explain:
PLEASE PRINT CUSTOMER INFORMATION
Name:
Address:
City: State: Zip Code:
Phone Number:
Signature:
E-ZPass Transponder Number:
License Plate: State:
Transponder Issuing Agency:
Entry Interchange:
Date & Time of Entry:
Exit Interchange:
Date & Time of Exit:
Type of Vehicle:
OFFICIAL USE ONLY:
Amount Paid: $ Amount Due: $ Credit: $
E-ZPass credits will be applied electronically!
33-11B
✔
300 East Park Drive
05.2017
FAX # 717.565.4311
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FORM 33-11B: Pennsylvania Turnpike Commission

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Completed 31 August 2021

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