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REQUEST FOR ADMINISTRATIVE APPEAL HEARING To: City Clerk City of Modesto P. O. Box 642 1010 Tenth Street Modesto, CA 95353 (209) 577-5396 WARNING! Pursuant to MMC 1-6.502, your appeal must be filed with the City Clerk within twenty (20) calendar days from the date of service of the administrative citation, notice and order, or notice of violation. 1. Name of Appellant 2. Address (Street) (City) (State) (Zip Code) 3. Telephone (Home) (Work) (Other) 4. Notice of Hearing to be sent to: (if different than above address): Address (Street) (City) (State) (Zip Code) 5. Would like to set up a payment plan? 6. Case Number 7. Please identify the type of violation identified on the citation. 8. What City Department issued the citation? 9. Why are you appealing the penalty and/or order imposed? 10. What facts support your contention no administrative penalty or a different penalty should be imposed 11. What facts support your contention no administrative order should be issued? PLEASE BE ADVISED that you must attach a copy of the ticket or citation to this Request for Administrative Appeal Hearing. PLEASE BE ADVISED that pursuant to Modesto Municipal Code Section 1-6.506 the hearing officer assigned to this matter may assess reasonable administrative costs associated with the hearing. In accordance with the requirements of Title II of the Americans with Disabilities Act (“ADA”) of 1990, the Fair Employment & Housing Act (“FEMA”), the Rehabilitation Act of 1973 (as amended), Government Code section 11135 and other applicable codes, the City of Modesto (“City”) will not discriminate against individuals on the basis of disability in the City’s services, programs, or activities. For more information, please visit the City of Modesto website at Date: Signature of Appellant