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STATE OF LOUISIANA
DEPARTMENT OF TRANSPORTATION AND DEVELOPMENT

P.O. Box 94042
Baton Rouge, Louisiana 70804-9042
www.dotd.louisiana.gov
BOBBY JINDAL
GOVERNOR
WILLIAM D. ANKNER
SECRETARY
Violation Ticket Payment Form

Ticket No.Date IssuedFine Amt
Total :
        Are you making payment of behalf of : Driver Owner DBA
        Name :
        Name of Cardholder :
        Card Number :
        Expiration Date :
        Filled Out By :
        Address :
        City :
        State :
        Zip Code :
        Phone Number :
        Fax Number :
        Need a Sales Slip sent to you? (Select One)

        Faxed Mailed

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