CITY OF TEMPLE CITY
REQUEST FOR ADMINISTRATIVE REVIEW OF NOTICE OF PARKING VIOLATION
To request an administrative review of your citation, complete SECTIONS 1, 2, AND 3. This request must be made within 21
CALENDAR DAYS of the issuance of a Notice of Parking Violation. Return this form and a photocopy of your citation to the
Temple City Public Safety, 5938 Kauffman Avenue, Temple City, CA 91780. Your statement will be evaluated and a
response will be mailed to you within 21 CALENDAR DAYS of receipt.
Citation No. __________________ Issue Date ________________ Lic No. ________________ Code Section ____________
Zip Code Tel No. __________________________________
List below all pertinent information as to why you believe this parking violation should be dismissed. Attach a PHOTOCOPY
of citation and any additional pertinent information. Copies will not be returned.
I hereby affirm and certify under penalty of perjury that the foregoing statements are true and correct to the best of my
FOR CITY USE ONLY
PARKING VIOLATION: [ ] UPHELD
* Make checks payable to:
Temple City Public Safety
5938 Kauffman Avenue
Temple City, CA 91780
Bail Amount $ Receipt No. Date Cash Check
PARKING VIOLATION: [ ] DISMISSED
[ ] Annual Permit No.