City Of Indio Form Ce-200 - Admin Hearing Request Form printable pdf download

City Of Indio Form Ce-200 - Admin Hearing Request Form

FOR STAFF USE ONLY

NAME OF HEARING OFFICER: JAMES BUTZBACH

MAILING ADDRESS: 100 CIVIC CENTER MALL

[ ] IN PERSON HEARING

CITY AND ZIP CODE: INDIO, CA 92201

[ ] HEARING BY DECLARATION

APPEAL DUE DATE: ______________________________________

CITY OF INDIO

DATE FORM MAILED/SUBMITTED/EMAILED: _________________

vs.

DATE RECEIVED:_________________

DEFENDANT:

CITATION NUMBER:

REQUEST FOR ADMINISTRATIVE CITATION HEARING

(INDIO MUNICIPAL CODE, § 11.06)

CASE NUMBER:

REQUEST FOR ADMINISTRATIVE CITATION HEARING

[ ] In Person.

1. I am requesting a hearing

[ ] via Written Declaration.

2. The facts contained in the Declaration of Facts on the reverse are personally known to me and are true and correct.

3. EVIDENCE

The following evidence supports my case and includes everything I want the hearing officer to consider in deciding

my case:

[ ] photographs (specify total number):

e. [ ] diagram

[ ] registration documents

f. [ ] repair receipts

[ ] property ownership documents

g. [ ] insurance documents

[ ] inspection documents

h. [ ] other (specify):

VIOLATIONS CONTESTED (Type or print only. List which cited violations you are contesting and a brief explanation of why you

contest liability for the violation.)

(Declaration continued on reverse)

City of Indio Form

INDIO MUNICIPAL CODE, § 11.06

REQUEST FOR ADMINISTRATIVE CITATION HEARING

CE-200 [January 2016]

(Page 1 )

City Of Indio Form Ce-200 - Admin Hearing Request Form