Required fields are marked with asterisks (*)

Payment Plan

Additional Information to Accompany Application
for Extension of Time to Pay Fine

Full Name

Date of Birth

Email Address:

Driver's Licence No.:

Financial Institution (Bank):

Bank Address:

Income Source:

Next of Kin:

Ticket Number(s):

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

Signature

Clear

Date:

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.

**Providing email address is providing consent to receiving notices and reminders via email.

Payment Plan

Additional Information to Accompany Applicationfor Extension of Time to Pay Fine

Additional Information to Accompany Application
for Extension of Time to Pay Fine