Required fields are marked with asterisks (*)

Request for Screening Officer Review

A person who wishes to appeal 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 By-law 2022-54, as amended.

Required Documentation

Please upload a copy of the issued Administrative Monetary Penalty.

Reasons to Dispute the Administrative Monetary Penalty

Subject Property in Huntsville

Unit Number

Street Number

Street Name

P.O. Box Number/ RR Number

City or Town

Lot

Concession

Reference Plan Number

Owner Information

First Name

Middle Name(s)

Last Name

First Name

Middle Name(s)

Last Name

Name of Corporation or Partnership (If applicable)

Unit Number

Street Number

Street Name

P.O. Box Number/ RR Number

City or Town

Postal Code/ ZIP Code

Phone Number

E-Mail Address

Please upload the issued Administrative Monetary Penalty

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Authorization

I/We confirm that I/We certify that:

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

By checking Yes, I confirm that I have read and understood the above and I am attesting that the information provided on this form is true and correct and submitting is equivalent to my authorized signature.

Yes

Date

Collection of Information

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 appeal to the Municipal Licencing Committee. Questions about this collection can be directed to the Clerk’s Department, Town Hall, 37 Main Street East, Huntsville, ON, P1H 1A1, 705-789-1751.