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Forms

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Letter of Authorization

Please complete this form to authorize a agency or individual to act on your behalf in regards to a Penalty Order review.

How many Penalty Orders are being reviewed?
 
What is the reason for your appeal?
 

Agent information

Is the Agent a Paralegal or Lawyer?
 

Fine responsbility

I am aware that if there is a fine to be paid after the Screening or Hearing appearance, the ultimate responsibility to pay the fine(s) rests with the Registered Owner of the vehicle, in accordance with Section 5 of Ontario Regulation 355/22 made under the Highway Traffic Act.

Privacy statement

Information contained on this form is collected under the authority of the Municipal Act. Information collected will be used and managed by the Township of Severn in accordance with the Municipal Freedom of Information and Protection of Privacy Act for general municipal operationsIf you require additional information, please view our Freedom of Information and Routine Disclosure Policy.

Please indicate that you've read and understand the above fine responsibility statement and the privacy statement
 
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