APPLICATION FOR EXTENSION OF TIME TO PAY FINE

ONTARIO COURT OF JUSTICE
PROVINCE OF ONTARIO

Under Section 66.0.1 of the Provincial Offences Act

Form 125
Courts of Justice Act
R.R.O. 1990
Reg. 200

Required fields are marked with an asterisk (*).

I, (name of defendant)

of (current address including apartment number)

Municipality (town/city)

Province

Postal Code

Phone Number

make this application in good faith and not to evade payment of the fine. In support of this application, I confirm and assert as follows:

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

Offence Number

Offence Description

Conviction Date

Time Given to Pay

Court ordered fine amount ($)

Amount paid to date ($)

Amount outstanding ($)

2. My employment status is:

Employed

Unemployed

Corporate Defendant *

* 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.)

(Check if applicable)

Additional information/supporting documentation attached below.

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

Yes

6. I previously obtained

extension(s).

The last extension of time for payment expired/will expire upon

Date

Signature of Defendant (Name)

POA 0809 (May 10, 2021) CSD

Personal information contained on this form is collected under section 17 of the Municipal Freedom of Information and Protection of Privacy Act, and will be used to respond to your request. Questions about this collection may be directed to the Freedom of Information and Privacy Coordinator for the City of Windsor, 350 City Hall Square West, Suite 530, Windsor, ON N9A 6S1 or 519 - 255 - 6100 Extension 6578.