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Screening Review Request - AMPS

Every person who is issued a Penalty Notice has the right to dispute the Penalty Notice by requesting a Screening Review within 15 days of the issuance of the Penalty Notice. Screening Reviews are conducted via email.

Section 1 - Penalty Notice Information

Penalty Notice Number

Offence Date

Location of Offence

Section 2 - Defendant Information

First and Last Name

Phone Number

Email Address

Mailing Address

City/Town

Province/State

Postal/Zip Code

Country

Will you be representing yourself?

Yes

If you responded "no" to the question above, please complete an Agent Authorization Form in addition to this form.

Section 3 - Reason for Review

Please provide a factual and detailed explanation of the reason(s) for your Screening Review.

Please upload supporting documents associated with your request for a Screening Review:

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

PLEASE NOTE: Supporting documents help estabilsh the validity of the request for a Screening Review. For example, a death certificate, police report, medical note, photographs or accessible parking permit may constitute supporting documentation.

If paying the Administrative Monetary Penalty will cause financial difficulty and you require additional time to pay, please send all supporting financial documents to support your claim. If you are unable to meet the identified timelines, please complete a Request for Extension of Time.

By signing this form, I certify that all information provided is true and accurate. I will notify the Township if any of the information changes before the review date.

Signature

Clear

Date

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