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Request for Screening

-TOWN OF-

GRIMSBY

PENALTY NOTICE RECIPIENT

First Name

Last Name

Street Address

City

Province

Postal Code

Phone Number (Preferred number)

Cell Number

PENALTY NOTICE INFORMATION

In order to dispute a penalty YOU MUST WITHIN 15 DAYS from the date of infraction, schedule an appointment for a review by a Screening Officer.

Penalty Notice Number

Penalty Date

Plate Number

Offence

Please select an option best for you

Over the phone (An appointment time will be scheduled. Failure to appear will result in additional charges. The Officer will call you at the set time for the appointment)

Written

In person screening (An appointment time will be scheduled. Failure to appear will result in additional charges.)

If you do not select an option, you will be deemed not to dispute the offence, which will result in debt owing to the Town of Grimsby and your Ontario Vehicle permit not being renewed.

REASON FOR SCREENING

You are required to provide specific reasons

Please provide a factual and detailed explanation of your reasons for your Screening Request.
If you wish to support your Screening with images or other documentation please attach them to this request.
The Screening Decision will be sent to you.

*Note that any evidence not presented at your Screening is inadmissible at any future Hearing

Enter explanation below:

Attachment(s) included (please check the relevant box):

Yes

STATEMENT OF PENALTY NOTICE RECIPIENT

I represent and warrant that:

I am the registered owner of the vehicle;
I acknowledge that if I fail to appear and to remain at my scheduled Screening until my matter has been determined by the Screening Officer, I will be deemed to have abandoned my request for a screening, the Administrative Penalty will be affirmed, and I will be liable for an additional fee for having failed to appear (currently $50.00); and
I have read and understood the conditions of this application.

SIGNATURE:

Clear

DATE:

THANK YOU FOR YOUR INFORMATION

If the Screening Request has been received within 15 days of the Penalty Notice being issued:

Penalty Notice payment deadline will be suspended until the Decision has been issued.
On receipt of your screening request, a time will be set for your review and you will be notified by email.
If you prefer a “written screening”, an Officer will review your comments and evidence and a decision will be issued to you by email.
If the Penalty is affirmed or reduced, you will have 15 days from the date of the Decision to make payment.
A late payment penalty will be applied after 15 days resulting in a debt to the Town of Grimsby and your Ontario Vehicle permit not being renewed.
If you wish to request a review of the Screening Decision by a Hearing Officer, you must do so within 15 days of the Screening Decision being issued.

Personal information contained on this form is collected and will be used for the purpose of administrating the Town's Administrative Penalty process. Questions about this collection should be directed to the Town Clerk at 905-945-9634

By clicking this box you agree that you have read, understood and accept the rules and requirements of the Screening Process.

Yes