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Get IL Non-Standard Settlement Request

___________________________________ License Plate(s): ____________________________ I-Pass: Yes or No (Circle) If yes, I-PASS Account #: Hearing Date: ______________________________ Amount owed: Total number of persons in household: _________ TOTAL: $ ___________ Amount Previously Paid $ ____________ Tolls $ ________ Pre-escalation fines: $ _________ Escalated Fines: $ __________ Reason for Violations/Hardship: ____________________________________________________________________ ______________.

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