Parking Citation/Impoundment Appeal Statement

Parking Citation/ Impoundment Appeal Statement

Please complete the information below and submit to the Dayton Police Department no later than 7 days after the issue date that is listed on your citation. If you do not submit a formal hearing request or you fail to pay the fines on your citation within these seven (7) days, the citation will remain valid and your fine(s) will increase. Once the form has been completed, a copy will be given to you for your records.

Name(Required)

First Last

Email

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Citation Number(Required)

Date of Citation

Violation Type Appealed

Vehicle Year, Make, and Model

Vehicle License Plate Number

Type of Ownership Interest

I appeal the above citation on the following grounds:

Consent(Required)

I certify that I am the owner or operator of the above described vehicle and that the content of this appeal is true and accurate to the best of my ability and knowledge.

Date(Required)

MM slash DD slash YYYY

Electronic Signature:(Required)

First Middle Last