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TEMPLATE FOR THE INFORMATION LETTER referred to in Article 24 [Cover page] … … [Name, address and telephone number of sender] … … [Name and address of addressee] INFORMATION LETTER regarding the failure to pay a road fee occurred in … [name of the Member State in whose territory there was a failure to pay a road fee] Page 2 On … a failure to pay a road fee with the vehicle with registration [date] number … make … model … was detected by … [name of the responsible body] [Option 1] (1) You are registered as the holder of the registration certificate of the abovementioned vehicle. [Option 2] (1) The holder of the registration certificate of the abovementioned vehicle indicated that you were driving that vehicle when the failure to pay a road fee was committed. The relevant details of the failure to pay a road fee are described on page 3 below. The amount of the financial penalty due for the failure to pay a road fee is … EUR/national currency.

(1) The amount of the road fee due to pay is … EUR/national currency.

(1) Deadline for the payment is …

You are advised to complete the attached reply form (page 4) and send it to the address shown, if you do not pay this financial penalty (1)/road fee (1). This letter shall be processed in accordance with the national law of … [name of the Member State in whose territory there was a failure to pay a road fee]. Page 3 Relevant details concerning the failure to pay a road fee (a) Data concerning the vehicle which was used in the failure to pay a road fee: Registration number: … Member State of registration: … Make and model … (b) Data concerning the failure to pay a road fee: Place, date and time where the failure to pay a road fee occurred: … … … … Nature and legal classification of the failure to pay a road fee: … … … … Detailed description of the failure to pay a road fee: … … Reference to the relevant legal provision(s): … … Description of or reference to the evidence regarding the failure to pay a road fee: … … (c) Data concerning the device that was used for detecting the failure to pay a road fee (2): Specification of the device: … … Identification number of the device: … … Expiry date for the last gauging: … … (1) Delete if not applicable.

(2) Not applicable if no device has been used. Page 4 Reply form (please complete using block capitals) A. Identity of the driver:

— Full name: … … — Place and date of birth: … — Number of driving licence: … delivered (date): … and at (place): … — Address: … … … … B. List of questions: 1. Is the vehicle, make …, registration number …, registered in your name? … yes/no (1) If not, the holder of the registration certificate is: … (name, first name, address) 2. Do you acknowledge that you failed to pay a road fee? yes/no (1) 3. If you do not acknowledge this, please explain why: … … Please send the completed form within 60 days from the date of this information letter to the following authority or entity: … at the following address … INFORMATION (Where the information letter is sent by the entity responsible for levying the road fee pursuant to Article 25): If the road fee due is not paid within the deadline set out in this information letter, this case will be forwarded to and examined by the competent authority of … [name of the Member State in whose territory there was a failure to pay a road fee].

If this case is not pursued, you will be informed within 60 days after receipt of the reply form or the proof of payment.

(1) / (Where the information letter is sent by the competent authority of the Member State): This case will be examined by the competent authority of … [name of the Member State in whose territory there was a failure to pay a road fee]. If this case is not pursued, you will be informed within 60 days after receipt of the reply form or the proof of payment.

(1) (1) Delete if not applicable. If this case is pursued, the following procedure applies: … … … … … … … … … … … … … … … … … … … … … … … [to be filled in by the Member State in whose territory there was a failure to pay a road fee – what the further procedure will be, Including details of the possibility and procedure of appeal against the decision to pursue the case. These details shall In any event include: name and address of the authority or entity in charge of pursuing the case; deadline for payment; name and address of the body of appeal concerned; deadline for appeal]. This letter as such does not lead to legal consequences.

Data protection disclaimer [Where Regulation (EU) 2016/679 is applicable: In accordance with Regulation (EU) 2016/679, you have the right to request access to, and rectification or erasure of, personal data or restriction of processing of your personal data or to object to the processing, as well as the right to data portability. You also have the right to lodge a complaint with [name and address of the relevant supervisory authority]. [Where Directive (EU) 2016/680 is applicable: In accordance with [name of the national law applying Directive (EU) 2016/680], you have the right to request from the controller access to and rectification or erasure of personal data and restriction of processing of your personal data. You also have the right to lodge a complaint with [name and address of the relevant supervisory authority].]