Required fields are marked with asterisks (*)

Request for Hearing Officer Review Form

Penalty Notice Recipient

First Name and Last Name (e.g. John Smith)

Street Address (e.g. 123 Jones Street)

Town, Province (e.g. LaSalle, ON)

Postal Code

Phone Number

Please choose a contact preference

Penalty Notice Information

Penalty Notice Number

Penalty Date

Plate Number

Please Choose Your Request

Will you be using an Authorized Representative to act on your behalf ?

Yes

Reason for Hearing Request

Please provide a factual and detailed explanation of your reason(s) for your review request. If you wish to support your Review with images or other documentation, please bring them with you at your scheduled In-Person Hearing Review.

Please provide a factual and detailed explanation of your reason(s) for your review request.

Statement of Penalty Notice Recipient

I am the registered owner of the vehicle (for parking penalty notices only); or the representing Agent.
I acknowledge that if I fail to appear and to remain at my scheduled In-Person Hearing Review until my matter has been determined by the Hearing Officer, I will be deemed to have abandoned my request for a Hearing Review. The Administrative Penalty will be affirmed and I will be liable for an additional fee of $100.00 for having failed to appear.
The Town of LaSalle is not responsible for the actions of Canada Post, nor the timelines of their delivery.
Failure to complete this form in its entirety may result in the Administrative Penalty and additional fees being affirmed.

I confirm that I have read and understand the conditions of this application.

Signature

Clear

Date

The personal information on this form is collected under the authority of the Municipal Act, 2001 and will be used for the purposes of responding to your request with respect to the Town’s Administrative Monetary Penalty System. Questions about the collection of this information can be directed to the Deputy Clerk, Town of LaSalle, 5950 Malden Road, LaSalle, Ontario N9H 1S4, 519-969-7770 ext. 1256.