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:

Land acknowledgement

The City of Kitchener is situated on the traditional territory of the Chonnonton, Anishinaabeg, and Haudenosaunee Peoples. We recognize our responsibility to act as stewards for the land and honour the original caretakers who came before us. Our community is enriched by the enduring knowledge and deep-rooted traditions of the diverse First Nations, Métis, and Inuit Peoples who live in Kitchener today.