Decision Information

OLT Case and/or File Number:

Decision Number:

Decision Issue Date:

Address and/or Legal Description of Property on Decision:

Municipality:

Region:

Requester Information

Last Name:

First Name:

Company Name or Association Name (Association must be incorporated – include copy of letter of incorporation):

Email Address:

Daytime Telephone Number: ext.

Alternative Telephone Number:

Mailing Address:

Unit Number: Street Number:

Street Name: P.O. Box:

City/Town: Province:

Country: Postal Code:

Required Fee

Fee = $20.00 x  Copies = Total Fee Submitted $

Payment Method: Certified Cheque     Money Order 
        Credit Card        Cash (In Person Only)
        Lawyer’s general or trust account cheque

If you wish to pay the fee(s) by credit card, please check the box above and OLT staff will contact you by telephone to complete the payment process upon receipt of the form.

Special Instruction

OFFICE USE ONLY

Request Received by:  
Date Request Received:

Fee Received: $         Date Mailed:

Processed By: