Republic of the Philippines

Province of Southern Leyte

MUNICIPALITY OF HINUNDAYAN

TRAFFIC CITATION TICKET

Ticket No.:
Place of violation:
Date and Time:
Apprehending Officer:

NAME :_________________________________
DRIVER’S LICENCE NO. :_________________________________
ADDRESS :_________________________________

TYPE OF VEHICLE : Motorcycle Tricycle Four Wheeled Bus Others

OWNERSHIP : Private Public Utility Government owned
PLATE NO. :
COLOR :

VIOLATION/S: (Please state the ordinance violated)

Ordinance No. 2011-85 (Helmet Ordinance)

Ordinance no. 2017-13 (Traffic Rules Ordinance)

Illegal Entry Illegal Right Turning Illegal Left Turning

Illegal Loading/Unloading Illegal Parking

Non-Observance of speed limit

You are hereby directed to appear at the municipal treasurer’s office for the outright payment of
fines imposed as provided in the ordinance within three (3) days after the issuance and acknowledgement
of this citation. Failure to appear means the government will now proceed in instituting the proper legal
action against the violator.

I hereby acknowledge that I have been cited for violation of the herein ordinance and that the
apprehending officer has sufficiently explained to me the consequences of my action/s if I fail to appear
to the appropriate office in the specified period given.

I hereby acknowledge that I have been cited for violation of the herein ordinance and that I will
not contest the violation and instead pay the prescribed fines outright and will not contest the violation.

____________________________
Name and Signature