Required fields are marked with asterisks (*)

Motion for Extension of Time to Pay Fine

Full Name:

Street Address:

Township:

Province

Postal Code:

Phone Number

Email Address:

1. I was convicted of the following offence and given the following sentence:

Offence Number

Offense Description

Conviction Date

Time given to pay

Court ordered fine amount ($):

Amount paid to date ($):

Amount outstanding ($):

2. My employment status is:

*Applies only where corporate entity has been convicted.

3. I am unable to pay the outstanding amount because: (Kindly set out what circumstances, such as financial, medical, employment, or other, have contributed to the fine not being paid within the time given.)

Please indicate "yes" and use the upload button below to attach documents:

Yes

4. I hereby apply for an extension of time for payment until:

5. This is my first application for an extension of time to pay

Date:

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Motion for Extension of Time to Pay Fine