Region of Waterloo Form

Home/Regional Government/Provincial Offences Court and Traffic Tickets

Required fields are marked with asterisks (*)

Provincial Offences Court

Automated Payment Request

This form is for fines over $1000 only

Ticket/File Number (ex: 4460 999 00 5861234Z 00 or 4460 999 20 12345 00)

Do you have more than one ticket?

Yes

No

First Name

Last Name

Driver's Licence Number

Date of Birth

Address

Unit Number

City/Town

Postal/Zip Code

Phone Number (10-digits)

Email Address

Do you have an extension of time to pay approved by the Court?

Yes

No

Submitted By

Date

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