IN THE PROVINCIAL COURT OF NOVA SCOTIA

APPLICATION TO EXTEND TIME TO PAY FINE


My name is: __________________________________________________________

 

My date of birth is _____________________________________________________


I hereby apply to the court to have the time extended to pay the fine ordered against me.

  

The fine was ordered to be paid by ____________________________, 201__.


(       )  To date I managed to pay a total of $________________  on the fine.


OR (       )  To date I have not been able to pay any amount towards the fine for the following reasons:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


I respectfully request further time pay the fine for the following reasons:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



In support of my application, I attach the following documents:

(Mark an X in the appropriate item)


(      )  my last income tax return

(      )  my most recent pay stub

(      )  statement from my employer confirming my current income

(      )  my most recent EI cheque stub

(      )  my most recent disability insurance cheque stub

(      )  confirmation of my level of social assistance benefits

(      )  note from my doctor confirming my medical condition

(      )  copies of my drug prescriptions

(      )  note from  __________________________ confirming that I am not in           receipt of any income

(      )  other___________________________________________________________

(      )  other __________________________________________________________

(      )  other __________________________________________________________


Contact information for the Defendant   


My address is: _________________________________________________________   

 

                    __________________________________________________________   

   

My phone number is:  ___________________________________________________   

   

Date signed:    ________________________________________________, 201____.         

   

My signature:   _________________________________________________________



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