Fillable PLEASE PRINT ALL INFORMATION (Port of Richmond)

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PLEASE PRINT ALL INFORMATION (Port of Richmond)

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PLEASE PRINT ALL INFORMATION
PARKING CITATION
ADMINISTRATIVE REVIEW
REQUEST
CITATION NO.
CITATION DATE
∕ ∕
PLATE NO.
REQUEST DATE
∕ ∕
REQUESTOR / OWNER INFORMATION
VEHICLE REGISTERED OWNER
REQUESTOR NAME
STREET ADDRESS
REQUESTOR PHONE(S) (H = HOME / C = CELL / W = WORK)
CITY ST ZIP
REQUESTOR EMAIL
ADMINISTRATIVE REVIEW REQUESTED FOR FOLLOWING REASON(S)
BROKEN PARKING METER
FALLEN/MISPLACED PERMIT/PLACARD
PARKING SIGN(S) WERE MISSING,
ILLEGIBLE, INCORRECTLY WORDED OR
DIFFICULT TO UNDERSTAND
OWNER DECEASED (ATTACHED COPY
OF DEATH CERTIFICATE)
VEHICLE DISABLED
SIGN/OTHER PARKING PROHIBITION
INSTALLED AFTER VEHICLE PARKED
THERE
PLATE INCORRECTLY ENTERED
LICENSE PLATES WERE STOLEN OR
WAS ISSUED (POLICE REPORT OR DMV
INFORMATION SUPPORTING CLAIM)
RESTRICTED PARKING PERMIT
MEDICAL EMERGENCY (COMPLETE
SECTION BELOW)
VEHICLE WAS STOLEN OR OWNERSHIP
TRANSFERRED AT TIME THE CITATION
WAS ISSUED (ATTACH POLICE REPORT
OR DMV INFORMATION SUPPORTING
CLAIM)
OTHER
Only forms that meet the criteria listed above will be accepted for an Administrative Review. Supporting documentation is required, such as pictures, repair
receipts or DMV information. Please attach.
DESCRIPTION/EXPLANATION OF MEDICAL EMERGENCY
BY MY SIGNATURE, I DECLARE THE INFORMATION SUBMITTED IN
REGARD TO THIS REQUEST FOR ADMINISTRATIVE REVIEW OF
PARKING CITATIONS IS TRUE AND ACCURATE TO THE BEST OF MY
KNOWLEDGE AND BELIEF.
SIGNATURE
DATE
INTERNAL USE ONLY
DATE RECEIVED
∕ ∕
DETERMINATION (EVALUATION ATTACHED)
□ CITATION JUSTIFIED □ CITATION NOT JUSTIFIED
REVIEWER’S INITIALS
DATE
∕ ∕
REVIEWER’S INITIALS
DATE
∕ ∕
900 EAST BROAD STREET, ROOM 102 ▪ RICHMOND, VIRGINIA 23219 ▪ 804.646.5700 ▪ FAX 804.646.5208 ▪ www.richmondgov.com REVISED 3/2018
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PLEASE PRINT ALL INFORMATION (Port of Richmond)

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Completed 29 July 2020

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