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2. Process for Submission
   Do not pay your citation if you plan to dispute it. Complete, print out and return this form within 21 calendar days of issuance of the parking citation. Return your printed form and any attachments using one of the following methods: Bring to 1010 10th Street, Second Floor, Suite 2100, Fax to 209-491-5920 or Mail to PO Box 3063, Modesto, CA 95353.
4. Are you filling this out within 21 days of the citation issuance?*

   1. Yes
   2. No
6. Submit Informal Review Request Online
   Submit Informal Review Request Online

   Please submit your request for Informal Review online if you are within the 21 calendar day deadline for disputing your citation.
8. Dispute Aknowledgement*

   1. I understand that by choosing this method of disputing my citation, that I must print and return this form within 21 calendar days of citation issuance.
10. First Name*
11. Last Name*
13. Address*
15. City*
16. State*
    -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMInnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontWashingtonWest VirginiaWisconsinWyoming
17. Zip Code*
19. Home Phone *
20. Cell Phone*
21. Work Phone
23. Citation Number*
24. Date Issued*
25. Vehicle License Number*
26. Last 4 Numbers of VIN Vehicle Identification Number*
28. Provide Copy of Citation

    1. I will include a copy of my citation with my completed Request for Informal Review form.
30. Please state why you believe the citation was issued in error*
32. Signature*
    Type your name in box for signature.
33. Date*
    Date
37. For more instructions on how to dispute a parking violation please visit the link below.
    Dispute Parking Citation Main Information Page
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38. Print Only

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