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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}

I, (name of defendant)

of, (current address including municipality, province and postal code)

Phone Number

Email (optional: To receive email confirmation that your application has been submitted)

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: (Please set out the circumstances, such as financial, medical, employment, or other, that have contributed to the fine not being paid within the time given)

I will pay, per month:

Please upload any additional or supporting documentation here. (Optional)

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

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

Date:

Signature of the Defendant

Clear