CITY OF MOORPARK
799 MOORPARK AVENUE
MOORPARK CA 93021
INITIAL REVIEW OF PARKING CITATION
An Initial Review may be requested in writing only. Please be specific in the Statement of Facts in explaining why you
are requesting that the citation be dismissed. Please complete the front of this form and return it to our office
including the Parking Citation (it is not necessary to mail in the payment). We will mail results of this Review to you.
PLEASE PRINT
Name:
Citation No.:
Address:
Violation No.:
City:
Zip: Time Citation Issued:
Vehicle License No.:
Date Citation Issued:
H
ome Phone: ( ) Business Phone: ( )
STATEMENT OF FACTS:
(If you need additional space, please use the attached continuation page)
I declare, under penalty of perjury under the laws of the State of California, that the foregoing statement is true and
correct.
Executed by:
_______________________________ on _______________ at __________________
(Name)
(Date)
(City & State)
Page 2 of 3
CITY OF MOORPARK
799 MOORPARK AVENUE
MOORPARK CA 93021
INITIAL REVIEW OF PARKING CITATION
(CONTINUED)
Citation Number: _______________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
I declare, under penalty of perjury under the laws of the State of California, that the foregoing statement is true and
correct.
Executed by:
_______________________________ on _______________ at __________________
(Name)
(Date)
(City & State)
Page 3 of 3
(
(
F
F
O
O
R
R
O
O
F
F
F
F
I
I
C
C
E
E
U
U
S
S
E
E
O
O
N
N
L
L
Y
Y
)
)
Reviewed by: Date:
(Moorpark Police/Public Works Department)
Determination (Circle One): Appellant Liable Appellant Not Liable
Citation No.: Date Mailed:
The facts above have been reviewed and the above referenced citation HAS NOT been rec
ommended for dismissal. If
you wish to pursue this further, you must present this form to the City of Moorpark, 799 Moorpark Avenue, Moorpark,
CA or call (805) 517-6366, prior to the date indicated in your letter.
Signature Date
WRITTEN STATEMENT OF ADMINISTRATIVE HEARING OFFICER
Officer’s Name (Please Print) Date
Officer’s Signature
INITIAL REVIEW DETERMINATION/COMMENTS
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