1. About YouTitle*

First Name*

Last Name*

Property number and street*

Town / City*

County

Contact phone number*

Email address*

Mr Ms Miss OtherMrs

Dart Charge emails are sent from donotreply@dartford-crossing-charge.service.gov.uk. Add this email address to your safe senders list to avoid these being marked as spam.If you require statements ‘By Post’, you are agreeing to pay an additional administration charge of £2 that will be deducted from your Dart Charge account balance every calendar month. The statement will be sent to the address provided above.Tick Box to Confirm By Post

*Information must be provided

Apply for a Local Residents’ DiscountPlease write clearly and in CAPITALS. You may find it quicker and easier to apply online at www.gov.uk/dart-charge, click Start now and select Set up an account. You will need to make a payment for your chosen discount plan. If you wish to pay by Card, please call the Contact Centre on 0300 300 0120.

Postcode*

In accordance with our terms and conditions, to be eligible you must pay council tax to either Dartford Borough Council or Thurrock Council.

2. DocumentsIn order for us to process your application, we require clear copies of your documentation. We are unable to return these, please do not send originals.You must submit:

A copy of the V5C registration certificate for the vehicle in the name of the account holder

And

Current council tax statement showing your name and address

A bank or credit card statement no more than 3 months old

A utility bill no more than 3 months old (not a mobile phone bill)

An income support book or housing association rent document

Driving Licence

If the vehicle is a company or hire vehicle we will need the following:

A letter from the company confirming your address, that the vehicle is for your use only and that it is normally kept at the account applicant’s address (Not applicable for Class C vehicle).

Or

A copy of the vehicle lease document showing that the vehicle has been leased in your name

(Mandatory requirement for Class C vehicle).

3. Vehicle DetailsWe use automatic number plate recognition cameras and electronic tags to record details of all vehicles using the crossing. For more information about electronic tags and how to obtain one, please call Dart Charge Customer Services on 0300 300 0120.

Crossing Charges rates for a vehicle on an account:Vehicle class Type of vehicle Eligibility

A Motorcycles, mopeds and quad bikes Free

B Cars (including trailers), motorhomes and minibuses (with 9 or less seats including the driver’s seat) Yes

C Vehicles with 2 axles YesD Vehicles with more than 2 axles No

And one of the following:

Model (e.g. Mondeo)

Please select the vehicle class;

Vehicle Registration Mark (Number Plate)

Make (e.g. Ford)

Colour Country

Class B Class C

4. Plan OptionsWe will notify you to let you know when your discount is active. Please make other payment arrangements for crossings made before this confirmation.

Please tick one of the following options:

A £20 annual fee entitles you to unlimited crossings.

A £10 annual fee entitles you to 50 crossings. Further crossings will be charged at 20p per crossing and will be deducted from your account balance. You must maintain a credit balance balance at all times.

You can add other vehicles onto your account. These will be charged at the standard account rate.

You can top up your account balance online at www.dart-charge.gov.uk and select sign in online or by calling our Contact Centre on 0300 300 0120.

If your account balance falls below £0.00, your account will be closed, and you may receive penalty charge notices (PCNs).

Cheques or postal orders should be made payable to Dart Charge.

Please enclose Cheque or Postal Order and send to;Dart Charge, PO Box 842, Leeds, LS1 9QF

Value of Cheque or Postal Order Enclosed

5. DeclarationBy signing this form, I confirm that I wish to apply for a Dart Charge account. I also confirm that the details given on this form are, to the best of my knowledge, true and correct.

I understand that I must allow 10 working days for Dart Charge to process this application and that if I use the crossing before this application is processed, I must make alternative arrangements to pay the crossing charge(s) due to avoid penalty charge notices (PCNs) being issued to the registered keeper of the vehicle(s) associated to my account.

I confirm that I have read and fully understand the Dart Charge Terms and Conditions which can be obtained at www.gov.uk/dartcharge or by calling our Contact Centre on 0300 300 0120.

I confirm that I have read and accept the terms and conditions

Date*

Signature*

6. What To Do Next

DD/MM/YY

Please send this form, along with your payment, to: Dart Charge, PO Box 842, Leeds, LS1 9QF.

Please ensure that you pay the correct postage when sending your application form to us. We may make a deduction from your credit to cover insufficient postage paid.Please allow 10 working days for your account application to be processed. When your account is set-up, you will receive email confirmation that it is ready to use.

If You Change Your MindWe hope you will enjoy the benefit of the Local Residents’ Discount Scheme, however, if you change your mind you have the right to cancel this Agreement within 14 days after we receive your application. If you wish to cancel, call us on 0300 300 0120. Alternatively, write to Dart Charge, PO Box 842, Leeds, LS1 9QF, or use the cancellation form which can be found at www.gov.uk/dart-charge and in your Welcome Pack.

About Dart ChargeHighways England are authorised to collect the road user charge on behalf of the Secretary of State for Transport of Great Minster House, 33 Horseferry Road, London, SW1P 4DR. The Accounts, Local Residents’ Discount Scheme, Tags and website are operated on our behalf by emovis Operations Leeds Limited as our agent (company number 8703645, registered in England and Wales, with registered office at ST John's Offices, Albion Street, Leeds, LS2 8LQ (VAT number GB174301040).

All personal data will be processed in accordance with the GDPR and our privacy policy which can be found online: www.dartford-crossing-charge.service.gov.uk