Should you require additional information regarding the blocking of your toll device/s and/or card/s, please feel free to contact your UTA subsidiary or our RegistrierungsService department at ++49 (0)6027 509-617. V1.0 10/2014

Blocking of UTA MultiBox® Please complete this form and send it, free of charge (Europe-wide), to the following fax number:

00 800 / 88 26 83 62

UTA Customer Number:

UTA MultiBox® Type (please quote the relevant system in the schedule below)

Figure Abbreviation Device Country

MB UTA MultiBox® FRA (TIS PL + PTPL), ESP, PRT und BEL (Liefkenshoektunnel)

MBL UTA MultiBox®light FRA (TIS PL), ESP, PRT und BEL (Liefkenshoektunnel)

TIS UTA MultiBox®light FRA (> 3,5 t)

LIB UTA MultiBox®Liber-t FRA (till 3,5 t)

We are herewith blocking UTA MultiBoxes® issued for the following vehicle registration number/s:

Type Vehicle

Registration number

Device number Loss1 Theft1 Defective2 Return3 Replace-ment

Circumstances of loss/theft/defect: ______________________________________________________________________ 1 Damage compensation pursuant to the currently valid tariff list will be charged for UTA MultiBoxes® that cannot be returned due to loss or theft. 2 In the case of a reported defect with replacement order, the UTA MultiBox® reported as defect will be automatically completely disabled after 3 months. The defect device must have been returned / replaced within 30 days in order to avoid further rental charges / damage compensation claims. 3 The UTA MultiBox® must be sent back in an undamaged condition. Otherwise, the fees in the currently valid tariff list will be charged. UTA will immediately inform the relevant motorway companies as well as other parties concerned (service providers with regard to the possible use of the device or card) about the loss of the device or card and will point out the blocking of the corresponding device/card. However, UTA does not have any influence on the realisation of the relevant blocking. Consequently, UTA will not be liable for any illegal transactions which may have been effected by the time of the definite blocking processed by the motorway company or the service provider concerned. I herewith authorise UNION TANK Eckstein GmbH & Co. KG to save, process and use the data stated herein for all procedures relating to the present agreement. By signing the present registration form I also acknowledge having consulted and to accept the terms and conditions stated in the "UTA MultiBox® Contract“, which are available online in the UTA Exclusive Section.

___________________________________________ Company stamp, date and signature

Company

Contact person

Telephone number

E-mail address