Parking Tickets Payment and Appeal

2. Middleburg Police Department
4. Parking Ticket Appeal Request
7. 
9. Requested By:*
10. Contact #*
11. Email Address*
12. Date of Request
14. License Plate Number*
15. Ticket #
16. Date Issued
18. Violation*
20. Reason the ticket is being appealed*
22. Upload picture
24. Results of the request for to appeal:
    LEAVE BLANK OFFICIAL USE ONLY
26. Chief's response
28. Disposition:
29. Approved / Denied
30. Chief/designee signature:
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field