Request for a Hearing Review

In order to be considered for a Hearing Review, you must have received a Screening Decision and submit this form within 30 days of the Screening Decision date. If your Request is granted, you will receive a Notice of Hearing Review advising you of the format, date and time of the Hearing Review. If you do not attend the Hearing Review, the Screening Decision will be affirmed and an administrative fee of $100 will be added to the Administrative Penalty. 

If completing hard version of this request, you may submit it by email to aps@leamington.ca or in-person to the Municipality of Leamington, 111 Erie Street North, Leamington ON N8H 2Z9. 

If you require accommodation, please contact us at aps@leamington.ca. 

Penalty Notice Recipient Information

Penalty Notice Information

Reason(s) for your Hearing Request

• Please provide a factual detailed explanation of your reason(s) for your Hearing Request.
• If you wish to support your reasons with images or other documents, please attach them. 

Statement of Penalty Notice Recipient 

I represent and warrant that: 

• I am the person named on the Penalty Notice or I am the Agent authorized in writing to act on behalf of the person named in the Penalty Notice; 
• I acknowledge that if I fail to appear at the Hearing Review, I will be deemed to have abandoned my Request for a Hearing Review, the Screening Decision will be affirmed and I am responsible for any additional Administrative Fee(s) for having failed to appear; and 
• I have read and understand the conditions of this request. 

Statement - Online Form Submission 

By submitting this online form to the Municipality, the user acknowledges that the submission is deemed to be a substitute for the user's signature on the online form and signifies that the user has read, understood and agreed to the terms and conditions of the online form and any document referenced in the online form. 

Privacy Statement:  Personal information on this form is collected under the authority of the Municipal Act, 2001 and will be used for the purpose of administering the Municipality’s Administrative Penalty System. Questions about the collection of this information can be directed to the Manager of Legislative Services/Clerk, Municipality of Leamington, 111 Erie Street North, Leamington, N8H 2Z9, Telephone: 519-326-5761.