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Rec'd by: Date Update Complete Section A Citation Issuing Agency: Signature: Date: The City will notify you at least ten days before your Administrative Hearing. You may appear at the hearing and present your evidence or you may submit your case on your written statement above or by additional declarations under penalty of perjury. The Hearing Officer will render a judgment in your case and a copy of the judgment will be mailed to you at the address you provide above. Indicate in your correspondence if you wish to have your hearing by "WRITTEN DECLARATION" or "IN PERSON" you will be advised of your hearing date, time and location. Your administrative hearing request and penalty "AMOUNT DUE" must be received within 20 calendar days of the issuance of the citation. Failure to pay the total amount of the fine and return the completed hearing form within the timeframe specified shall render the appeal request incomplete and may forfeit your right for another opportunity to be heard. I understand that this Request for Administrative Hearing must be received by the City of Palmdale Public Safety & Community Relations Department within 20 days of the issuance of my citation and that I must pay the administrative penalty in full before or with this Request for Administrative Hearing or my request will be invalid and not be acted upon. I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT Name: Street Address: Reason for Contesting: Office Use Only INSTRUCTIONS: Complete Section A below including your reason(s) for contesting the citation. REQUEST FOR HEARING - Administrative Citation TO REQUEST AN ADMINISTRATIVE HEARING: Mail correspondence to the address listed below stating why you are requesting a hearing. Send any supporting evidence and the full "AMOUNT DUE" of the fine. If you are unable to pay the penalty deposit, you may be granted a waiver. You may obtain an "Application for Hardship Waiver" form from: Citation Service Center, P.O. Box 11370 Santa Ana, CA 92711, Phone # (866) 420-2894 or you may also download the Hardship Waiver form from City: Home Ph Other Ph City Of Palmdale State: Zip Code: