Required fields are marked with asterisks (*)

Request for Hearing Appeal

Please complete this form to request an appeal hearing.

Personal information contained on this form is collected and will be used for the purpose of administering the Township’s Administrative Penalty process. Questions about this collection should be directed to the Township of West Lincoln’s Freedom of Information Officer at 905-957-3346.

Penalty Notice Recipient

Name (first and last)

Home Telephone

Other Telephone

Address

City

Province

Postal Code

Mailing Address (if different)

Email Address

Authorized Representative - Optional

(See relevant Municipal Administrative Penalty By-law for list of authorized representatives)

Name (first and last)

Penalty Notice Information

Please provide the information found on the Penalty Notice

Penalty Notice No.

Penalty Date

Name on Penalty Notice

Offence

Information about Hearings

Hearings may be conducted in-person or virtually
Appeal Hearings cannot be rescheduled or adjourned

Type of Hearing Requested

In-Person Appeal (The Appeal Hearing Officer may choose to attend an in-person Appeal Hearing virtually. You would be provided a meeting room and a computer in this circumstance.)

Virtual Appeal (Email required)

Reason for Appeal - You are required to provide specific reason(s). Please provide a factual and detailed explanation of your reason(s) for your Appeal Hearing request.

If you wish to support your Appeal Hearing with images or other documentation, please attach your files. The Hearing Officer's decision will be provided to you at the Hearing.

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

Statement of Penalty Notice Recipient

I represent and warrant that:

I am the registered owner of the vehicle identified on the issued Penalty Notice; or

I am the person named on the Penalty Notice (for non-parking Penalty Notices only).

I represent and warrant that:

If I authorize an "Authorized Representative" to accompany me and acton my behalf in this matter (as permitted) I also understand that I must attend with the "Authorized Representative".

I represent and warrant that:

I acknowledge that if I fail to appear and to remain at my scheduled Hearing until my matter has been determined by the Hearing Officer, I will be deemed to have abandoned my request for a Hearing, the Administrative Penalty will be affirmed, and I will be liable for an additional fee for having failed to appear ($100.00 for parking or $250.00 for non-parking).

I have read and understand the conditions of this application. (Signature)

Clear