In the matter of the contravention of (specify designated provision) by (identify contravener)
It is hereby certified that, at the conclusion of the proceedings held before this Tribunal on (specify date), I assessed the amount of $(specify amount) to be paid by (identify contravener) on or before (specify date) as a penalty in respect of the contravention of (specify designated provision), which occurred on (specify date).
Dated this day of , 20
Signed by: Name of Tribunal Member
Address of Tribunal
- Date modified: