In the matter of the contravention of (specify designated provision) by (identify contravener)
It is hereby certified that, on appeal of the determination of (identify Tribunal member) on (specify date), the Tribunal determined 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 Each Tribunal Member Considering the Appeal
Address of Tribunal
- Date modified: