PLEASE PRINT CLEARLY . F ill out the upper portion of this form completely and sign. Keep your original citation and a photocopy of this completed form
for your records.
Date of Appeal: __________________________ Citation Date: _________________________ Citation Number: ____________________________________
License Plate No.: ___________________________________ State: _______________________ Vehicle Expiration Date: _________________________
Statement (If needed, you may attach one additional page of text or a photograph):
Violator Name: CWID #
Last First MI
Violator Phone # Circle One: CSM Student Faculty Staff Visitor
Name and Address of Registered Owner:
My signature below affirms that the above information is true and correct and that I understand and agree with the directives provided on the
instructions. With such understanding, I request to appeal the citation listed above. As a result of a denied appeal, I agree to pay all fines within
5 working days from the date on the denial letter. Unpaid fines will be forwarded for collection and additional penalties may be assessed. I
understand that no supplementary appeal process is available for CSM citations/violations and further agree that the referee’s
decision is final and binding.
Your Signature is required… This Appeal WILL NOT be processed without it!
OFFICE USE ONLY (DO NOT WRITE BELOW THIS LINE):
Date Received at PS: Fine Amount for this Ticket: $
History of Citations:
Officer Signature: Date:
Apeal Sustained and Summons Voided… No Fine!
Appeal Denied… Full Fines are Due!
Appeal Denied… However there are mitigating circumstances. Original fine reduced to $
Frivolous/Groundless… Fines Doubled!
Referee Signature: Date: