NO MEANS OF PAYMENT INCIDENT FORM
INCIDENT DETAILS:- PLEASE COMPLETE ALL SECTIONS IN BLOCK CAPITAL
VEHICLE DETAILS:- PLEASE COMPLETE ALL BOXES IN BLOCK CAPITALS
WARNING:- THIS IS A DECLARATION AND AGREEMENT TO PAY WITHIN (48HOURS)
- I here by agree to return to pay the sum shown above for the fuel obtained within 48hrs of the incident time. Payment should be made to the site from which the fuel was taken with a copy of this form. For convienience, payment can also be accepted by telephone, for which an additional Administration charge of £13.80 will be due on payment.
- I here by understand that I will be liable for the amount stated above with all cost enforcing this agreement against me.
- I here by declare that all information given by me on this form is true to the best of my knowledge and belief.
- I here by understand the this agreement provides that in an event of non-payment of the full amount within 48hrs of todays date. I accept charges will be payable and legally recoverable from me.
- Administration fee of £38.40+ VAT
- Any agents fees, Court costs and all charges incurred pursuing me.