Required fields are marked with asterisks (*)

Request for Review by Screening Officer

A person who wishes to submit a Request for Review by Screening Officer for the issuance of an Administrative Monetary Penalty shall file this complete application within 15 days of the issuance of an Administrative Monetary Penalty, as per the Administrative Monetary Penalty System (AMPS) By-law.

Required Documentation: Copy of the issued Administrative Monetary Penalty

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Reason(s) to dispute the Administrative Monetary Penalty:

A. Property Information (Where Administrative Penalty Was Issued):

Building Number and Street Name:

Unit Number:

Location:

Postal Code:

Plan Number/Other Description:

B. Owner Information

Name:

Corporation or Partnership:

Street Address:

Unit Number:

Location:

Municipality:

Postal Code:

Province:

Email Address:

Telephone Number:

Please attach any additional documentation that you feel would support your dispute.

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C. Declaration of Owner

1. The information contained in this application and any other attached documentation is true to the best of my knowledge. 2. If the owner is a corporation or partnership, I have the authority to bind the corporation or partnership.

Date:

Personal information contained in this form is collected under the authority of the Municipal Act, S.O. 2001, c.25, as amended and will be used to process the applicant’s Request for Review of the Screening Officer. Questions about this collection can be directed to the By-law Division, 148 Line 7 South, Oro-Medonte, ON L0L 2E0, 705-487-2171, municipallaw@oro-medonte.ca.