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Administrative Review Request for Town Ordinance Violation
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Date of violation
City, State, Zip Code
In accordance with applicable town ordinances, you have 21 days from the date the violation was issued to submit this request for review of an ordinance violation. Please provide a written or typed statement in the space provided (attach additional sheets if necessary) as to why you feel the violation was issued in error. Materials submitted for review will not be returned.
Please check one of the following options:
I request a formal hearing on this matter.
I DO NOT request a formal hearing on this matter.
Driver's license #
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