Request for extension of time to request a screening review

Pursuant to Section 2019-039, as amended, of the City of Kitchener

To the Administrative Monetary Penalty System Screening Officer,

I hereby request an Extension of Time to Request a Screening Review of the Penalty Notice described below

Please print (* indicates required information)

Penalty notice number

Penalty notice issued on

Vehicle licence plate number

First name

Last name

Your street address

Your city

Your postal code

Phone number

E-mail address

The mitigating or extenuating circumstances that warrant an extension of time are: