PARKING CITATION ADMINISTRATIVE REVIEW REQUEST

Note: All fields marked in * are required

CITATION INFORMATION

CITATION NO *

CITATION DATE *

PLATE NO *

REQUEST DATE

REQUESTOR/OWNER INFORMATION

FIRST NAME *

MIDDLE INITIAL

LAST NAME *

STREET ADDRESS 1 *

STREET ADDRESS 2

CITY *

STATE *

ZIP *

HOME PHONE

EMAIL ADDRESS *

WORK PHONE

EXT

ADMINISTRATIVE REVIEW REQUESTED FOR FOLLOWING REASON

Broken or malfunctioning parking meter

Fallen or misplaced permit or placard

Owner deceased

Missing, illegible, ambiguous or incorrectly worded sign

Stolen or lost license plate

Sign or other parking prohibition installed subsequent to parking

Disabled vehicle

Error entering plate at meter

Stolen or transferred vehicle

Medical emergency (explain)

Other (explain)

Only forms that meet the criteria listed above will be accepted for an Administrative Review. Supporting documentation is required, such as pictures, repair receipts or DMV information. Please attach. DESCRIPTION/EXPLANATION OF MEDICAL EMERGENCY

BY MY SIGNATURE, I DECLARE THE INFORMATION SUBMITTED IN REGARD TO THIS REQUEST FOR ADMINISTRATIVE REVIEW OF PARKING CITATIONS IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE AND BELIEF.

SIGNATURE *

DATE *

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