Ontario Court of Justice
Province of Ontario
Affidavit in Support of a Request for Reopening
Under Section 11 or Subsection 19(1) of the Provincial Offences Act, or
Section 205.13 or Section 205.23 of the Highway Traffic Act
Form 102
Courts of Justice Act
O. Reg. 200
Family Name/Company Given Name
Street Address
Postal Code
make oath/affirm and say as follows:
1. I was convicted without a hearing on
Date Convicted
of the offence of
Offence Charged
contrary to
Type of Act you were charged under
Section you were charged under
2. (a) I was unable to appear at my hearing through no fault of my own because:
State reason (Enter reason why you did not appear in court)
or (b) a notice or document relating to the offence was not delivered to me, namely:
Identify document (Enter what document/notice did you not receive)
3. The conviction first came to my attention on:
Date you became aware of the conviction (DD/MM/YYYY)
Sworn/Affirmed before me at:
This day of , year 20
A Commissioner, etc.
Signature of Defendant
Note: Section 86 of the Provincial Offences Act provides:
Every person who makes an assertion of fact in a statement or entry in a document or form for use under this Act
knowing that the assertion is false is guilty of an offence and on conviction is liable to a fine of not more than
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