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2. Date*
3. Ticket Number*
4. E-Mail*
6. License Plate Number*
7. License Plate State*
9. Name*
10. Phone Number*
12. Address*
14. City*
15. State*
16. Zip Code*
20. REASON FOR PROTEST*
22. Instructions:
    Please complete entire form within five (5) days of ticket issuance date. The ticket will be in a suspended file, pending the appeal process. If your protest is approved, you will hear nothing further. If your protest is denied, you will receive an e-mail notice to pay the ticket within five (5) working days to avoid penalties. At that time payment should be sent to the Finance Office, 1630 8TH Avenue, Moline, IL 61265.
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24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit Submit and Print

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