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Application for Extension of Time to Pay Fine

First Name

Last Name

Street Address

Apt/Unit/Suite/PO Box (if applicable):

Municipality

Province

Postal Code

Phone Number

Email Address

1. I was convicted of the following offence and given the following sentence:

Offence number:

Offense description

Conviction date

Time given to pay

Court ordered fine amount ($):

Amount paid to date ($):

Amount outstanding ($):

*Applies only where corporate entity has been convicted.

3. I am unable to pay the outstanding amount because: (Kindly set out what circumstances, such as financial, medical, employment, or other, have contributed to the fine not being paid within the time given.)

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4. I hereby apply for an extension of time for payment until:

Previous number of extension(s) obtained:

The last extension of time for payment expired/will expire upon:

Date: