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Request for a Screening Review

The Town of LaSalle issues Penalty Notices (By-law and Parking "tickets") for various infractions under the Administrative Monetary Penalty System (AMPS).

If you have received a Penalty Notice, you may request review of the Administrative Penalty by the Screening Officer using this form.

The Request for a Screening Review must be filed within 15 days of the "Date of Issue" as noted on the Penalty Notice, by the person to which the Penalty Notice applies. If the Person who received the Penalty Notice has a valid reason for missing that deadline, the Person may complete the "Request for Extension of Time for a Screening Review" form, and the Screening Officer will review your reason(s) and decide whether or not to grant an extension.

Please be sure that all information, including your contact information, is accurate and complete.

Penalty Notice Recipient Information

Last Name or Single Name

First Name

Middle Name (if applicable)

Primary Phone Number

Email Address

Street Number

Street Name

Apartment/Unit/Level (if applicable)

Town

Postal Code

Penalty Notice Information

Penalty Notice Number

Penalty Date

Plate Number OR Address of Infraction

Please provide a detailed and factual explanation of the reason(s) for disputing the Penalty Notice. If it is found that you have provided untrue information or if you have not provided enough detail, your Request for a Screening Review may be denied.

Please upload any document you think may support your Request for a Screening Review

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Requested Meeting Format of Screening Review

I am requesting that a Screening Officer review my Administrative Penalty, and I wish to (check one box):

Meet with the Screening Officer by telephone for the Screening Review

Meet with the Screening Officer via Zoom for the Screening Review

Meet with the Screening Officer in person, at the Civic Centre, during regular business hours for the Screening Review

Have the Review undertaken by the Screening Officer independently, without meeting with the Screening Officer

Claim of Financial or Undue Hardship

Will you be requesting that the Screening Officer reduce, cancel or extend the time for payment based on a claim of financial or undue hardship?

Yes

To support your claim or financial or undue hardship, please use the button below to upload evidence. Evidence may include but is not limited to documents related to the receipt of:

Old Age Security
Canada Pension Plan
Guaranteed Income Supplement
Ontario Disability Support Program
Ontario Student Assistance Program
Any other form of social assistance

Please upload evidence of financial or undue hardship here:

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Acknowledgement of the Penalty Recipient

I acknowledge that the information I have provided on this Request is true and correct, to the best of my knowledge.

I understand that the submission of this Request does not guarantee that a Screening Review will be granted and that the Screening Officer reserves the right to deny such a Request as per the AMPS By-law.

Failure to complete this Request may result in the Administrative Penalty (Penalty Notice) and any additional Administrative Fee(s) being affirmed.

Signature

Clear

Date of Request

Privacy Statement: Personal information collected on this form is collected under the authority of the Municipal Act, 2001 and will be used for the purposes of processing requests for Screening Reviews per the Town of LaSalle's AMPS By-law. Questions about the collection of this information can be directed to the Deputy Clerk, Town of LaSalle, 5950 Malden Road, LaSalle, Ontario N9H 1S4. Phone: 519-969-7770 ext. 1256.