Fillable Roadside Memorial Sign Program (City of Ottawa)

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Roadside Memorial Sign Program (City of Ottawa)

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ottawa.ca
City of Ottawa, 110 Laurier Avenue West, Ottawa, ON K1P 1J1
City Clerk and Solicitor Department
namingottawa@ottawa.ca
Page of
Application:
Please submit your completed Roadside Memorial Sign Application Form and supporting documentation using one of the
following options:
Option 1 - by e-mail to: namingottawa@ottawa.ca
Option 2 - by mail to: c/o The Commemorative Naming Program
City Clerk and Solicitor Department, City of Ottawa
110 Laurier Avenue West, Ottawa, ON K1P 1J1
You will receive confirmation of receipt of your application within five (5) business days.
City of Ottawa Responsibilities
• Upon approval of an application, an authorized memorial sign will be fabricated and installed as soon as practicable.
• The sign will be actively maintained for two (2) years.
• After two (2) years, the City will contact the nominator to determine whether they would like to have the sign removed
and given to them or for the sign to be left up without maintenance.
• Signs left up beyond two (2) years will be removed when necessary due to deterioration.
Process
• A request may be made by a family member or friend.
• An application form must be completed and signed by an immediate family member of the nominee.
• An Ontario Provincial Offences Act check is required for the nominee. The check is initiated and reviewed by the
City of Ottawa.
• A sworn affidavit* must be submitted by the nominator with the application form (see Appendix 1).
• The fee for the memorial sign is $250 plus HST and must be paid to the City once the application has been
approved. The fee covers the cost of fabrication and maintenance of the sign for two (2) years.
• After two years, the nominator will be given the option for the sign to be removed and provided to them
or to be left up without maintenance.
• Nominators will be given a one-time option of having a new sign installed for $250, plus HST.
• The nominator can ask for the sign to be removed and turned over to them at any time.
*Any fees associated with a sworn affidavit are the responsibility of the nominator.
The City of Ottawa assists families and loved ones that wish to memorialize those who have lost their lives in traffic incidents,
such as motor vehicle collisions and pedestrian or cycling collisions, through the Roadside Memorial Sign Program. The sign
will serve to commemorate the passing of a loved one, while encouraging safer driving. Only residents of Ottawa may be
commemorated through this program.
Roadside Memorial Sign Program
ottawa.ca
City of Ottawa, 110 Laurier Avenue West, Ottawa, ON K1P 1J1
City Clerk and Solicitor Department
namingottawa@ottawa.ca
Page of
Name of Nominator:
Relationship to victim:
Postal Code:
Province:
City:
Mailing address:
ext.Workplace:
E-mail address:
Telephone:
Home:
Cell:
Name(s) of Victims(s) (nominee):
Date of Birth: Date of Passing: Date of incident:
Location of incident:
A. Requestor's Information
B. In Memory of
The Sign installed will read: “Drive Safely. In memory of “name(s) of victim(s)”
ROADSIDE MEMORIAL SIGN APPLICATION FORM
ottawa.ca
City of Ottawa, 110 Laurier Avenue West, Ottawa, ON K1P 1J1
City Clerk and Solicitor Department
namingottawa@ottawa.ca
Page of
C. Additional Information
An Ontario Provincial Offences Act check for the nominee is also required. This check is conducted to ensure there are no extensive
outstanding convictions under the Provincial Offences Act in the nominee's name. Provincial offences are non-criminal charges
and include offences committed under the Highway Traffic Act, the Liquor Licence Act, the Trespass to Property Act, and the
Compulsory Automobile Insurance Act as well as municipal by-law offences. The City of Ottawa's City Clerk and Solicitor
Department will complete this check on behalf of the nominee.
In addition to the above, a sworn affidavit* (see Appendix 1) must be provided to the City Clerk's Office along with this
application form. The affidavit provides information with respect to outstanding offence convictions or infractions under a federal
or provincial statute.
*Any fees associated with a sworn affidavit are the responsibility of the nominator.
Please note that an outstanding conviction or infraction under any of the above stated acts and offences may result in the
disqualification of an application.
The individual I am requesting to be memorialized was the victim of a fatal traffic incident and did not commit a serious
offense that was determined to be the proximate cause of the incident.
D. Consent
To process this request, an immediate family member of the victim must consent to:
- a Provincial Offences Act check from the Province of Ontario
- providing the sworn affidavit to the City
- the release of the status of the clearance checks
Does the immediate family member consent to the three above items?
Nominator's Signature
Signature of Immediate Family Member
(If different from above)
Date
Date
Yes No
Yes No
“Personal information collected on this form is in accordance with Section 10(1) of the Municipal Act, and will be used solely for
the purpose of this Roadside Memorial Sign Program application, and kept confidential. Questions concerning the collection of
personal information may be addressed to the Coordinator, Safer Roads Ottawa Program by contacting 3-1-1.”
ottawa.ca
City of Ottawa, 110 Laurier Avenue West, Ottawa, ON K1P 1J1
City Clerk and Solicitor Department
namingottawa@ottawa.ca
Page of
1. Was never convicted of an offence as set out in a Federal Statute.
2. Does not have any outstanding convictions or infractions as set out in the Ontario Provincial Offences Act and/or
any City of Ottawa Municipal By-laws.
3. I make this Affidavit in support of the Application Form for the Roadside Memorial Sign Program, City of Ottawa, and for
no improper purpose.
(victim)
MAKE OATH AND SAYTHAT TO THE BEST OF MY KNOWLEDGE,
,
I,
(Nominator Or Immediate Family Member)
AFFIDAVIT OF
To Be Completed By The Nominator Or Immediate Family Member To The Victim
Roadside Memorial Sign Program
A commissioner, etc.
(Nominator Or Immediate Family
Member)
SWORN BEFORE ME at the )
City of Ottawa, in the )
Province of Ontario, )
this day of , 201
)
)
)
, of the city of in the Province of
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Roadside Memorial Sign Program (City of Ottawa)

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Completed 4 September 2021

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