Office of the Village Clerk
243 Main Street, Johnson City, New York 13790
(607) 798-7861

PARKING TICKET DIVISION

Name: __________________________________________________   Date: _______________

Street: ___________________________________________________

City and State: ____________________________________________   Zip: _________________

Home Phone: ____________________    Work Phone: ____________________


Ticket Number: ____________________    Plate Number: ____________________

Date Issued: ____________________    Location: ______________________________

Time of the Violation: ____________________

VEHICLE DESCRIPTION:

Make: ____________________    Model: ____________________
Year: _____________________    Color: _____________________

Who is the REGISTERED Owner of the above vehicle?
____________________________________________________________________________

Who was OPERATING the vehicle?
____________________________________________________________________________

EXPLANATION (please be specific):
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________


Signature: ___________________________________    Date: ____________________

*PLEASE ATTACH THE ORIGINAL TICKET OR A COPY OF THE TICKET WITH FORM*
Return to above address, ATTN: Parking Ticket Division

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