Required fields are marked with asterisks (*)

Request for Screening Review

Use this form to dispute your ticket through a screening review.

You have 30 days to dispute your ticket after getting it.
Do not pay the ticket if you're requesting a review.
No late fees will be added during the review process.
Once the screening review is complete, you'll get the decision by email or mail.

Dispute one ticket per form. For multiple tickets, fill out a separate form for each.

Is this screen review request for a parking ticket?

Parking Ticket

Non-parking ticket

Your Name

Your Address, including postal code

Your Telephone Number

Your email address

Ticket Number

Ticket issued on

Infraction description (charge) listed on the ticket

Please explain the reasons why you are requesting a review of your ticket, including a detailed explanation.

Provide any supporting evidence and documents - if applicable

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

Declaration - By signing this form I certify that all information provided in this application is true and accurate. I will notify the city if any of the information changes before the review date.

Clear

To the extent that the following information constitutes personal information as defined in the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, chapter M.56 as amended, the information is subject to provisions of that Act and will be used for the purposes indicated or implied by this form. Questions about the collection of personal information should be directed to the Township Deputy Clerk, 24 Church Street West, Elmira, ON, N3B 2Z6, telephone (519) 669-6005.