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Motion for Extension of Time to Pay Fine

Pursuant to s. 66.0.1 (1) Provincial Offences Act

Note: If there are multiple fines outstanding, the application of payments received will be at the discretion of the Collections Unit. It is understood that enforcement will ensue immediately upon failure to pay according to the granted payment schedule. This may result in additional fees, the suspension of your driver’s licence, civil enforcement, and other collection measures.

This information is collected in accordance with Section 66(3) of the Ontario Provincial Offences Act and will be used in the administration and/or collection of outstanding fines which fall under the Provincial Offences Act.

Full Name:

Your Date of Birth:

Driver's Licence No.:

Street Address:

Apartment No.:

City:

P.O. Box No. (if applicable)

Postal Code:

Email Address:

Home Telephone No.:

Cell Phone No.:

Own or Rent?

Roll No.:

Financial Institution (Bank):

Financial Institution Address:

Are you Employed/Unemployed?

Next of Kin:

Ticket Number(s):

Reason you are applying for an extension of time to pay:

If granted, what is your proposed payment or payment schedule to take care of this debt:

Signature:

Clear

Signature Date: