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APPLICATION FOR REVOCATION,

SPECIAL CIRCUMSTANCES AND OTHER

Form B

INFORMATION
What happens if you ignore the Enforcement Order?

If you live in Victoria, an infringement warrant will be issued to the Sheriff to seize and sell your goods or to imprison you, additional
costs will be incurred.

I, (full name): ............................................................................... Date of Birth: ..........................


(PLEASE PRINT)

of (residential address): ..................................................................................................................

INFRINGEMENTS
REGISTRAR
USE ONLY

WARNING:

Postcode: ................................... Contact Phone Number: .............................................................


Third Party (full name)*: ...............................................................................................................................................................

If you do not pay the infringement penalty and prescribed costs or take one of the courses of action
outlined below, enforcement action will be taken against you. This action may include:

the issue of an infringement warrant authorising the seizure of your personal property

your driver licence or motor vehicle registration may be suspended and/or not renewed, and/or
not transferred

your motor vehicle may be immobilised (eg by wheel clamping), seized and sold

you may be subject to an attachment of earnings or an attachment of debts order

your real estate may be subject to a charge order and sale

you may be arrested pursuant to the Infringements Act 2006 and brought before the Court

*(If completing application on behalf of someone who has Special Circumstances provide your full name)

of (residential / business address): ................................................................................................... Postcode: .............................

OPTION 1:

Pay the amount due:


For payment details, please refer to your Enforcement Order Notice or contact the following numbers:
Melbourne:
(03) 9200 8222
Country Victoria Only:
1800 150 410

OPTION 2:

Ask for extra time to pay the amount:


Phone the Infringements Court during business hours on (03) 9200 8222, before the amount is due, to apply
for additional time to pay the fine, or to pay the fine by instalments.

OPTION 3:

Apply for Revocation of the Enforcement Order (ie for the Order to be cancelled and the case to be
heard in court):
If you believe you are not guilty of the offence or had a valid reason for committing the offence, you can apply to
have this order revoked. More information on revocations is available on (03) 9200 8222.

Relationship of Third Party**: ........................................................................................................................................................


**(Relationship of Third Party to person named in Enforcement Order eg Carer, Parent, Spouse, Treating Doctor, Psychologist)

Company Name***: ......................................................................................................................................................................


*** (Complete if Enforcement Order is in the name of a company)

Company Address: .......................................................................................................................... Postcode: .............................


(Provide company address where documents can be served)

In the above company I hold the position of: ..................................................................................................................................

............................................................
..............................................................
and I hereby apply to have the Order(s) revoked.

.............................................................

WHY SHOULD THE ENFORCEMENT ORDER BE REVOKED?


2
Please tick the appropriate box relevant to your application to have the Enforcement Order revoked:
SPECIAL CIRCUMSTANCES EXIST (READ OPTION 4)
EXTENSION OF TIME (READ OPTION 5)*
*(NOTE: This is not an extension of time to pay the Enforcement Order amount please refer to OPTION 2)
OTHER

Please provide details below:


I first became aware of this offence on ....../....../ 20......

Detach and Return this page

I am the person named in the Enforcement Order (or if a third party, a person authorised to apply on behalf of the person named in
the Enforcement Order, or company, a person authorised by the company to make this application) in the following Infringements
Court Case Number(s):

To apply for revocation you must fill in the attached written statement and return the form to the
Infringements Court by the due date for payment.
If you are stating that you were neither the driver nor the owner of the vehicle at the time the
offence was committed, you must complete Form A of the application.
If you did not receive the Infringement Notice, or are applying under Special Circumstances, or have
a other valid reason, you must complete Form B of the application.
What happens if I apply to have the Court Order revoked?
The Infringements Registrar of the Infringements Court will consider your application and if there are sufficient
grounds to justify revocation, the Enforcement Order will be revoked. The matter of the infringement offence will
then be referred back to the Enforcement Agency that issued the infringement (eg Police, Municipal Council) for
their consideration. They may decide to not proceed with the Infringement Notice or have it referred to a
Magistrates' Court for hearing in which case a hearing notice will be posted to you. You will be expected to
attend the Magistrates' Court hearing or have a legal representative appear on your behalf.
If the Order has been revoked due to a nomination being supplied, the Infringements Court may cancel the
Infringement Notice and the Enforcement Agency will be notified. If the Infringements Registrar decides that there
are insufficient grounds to cancel the Enforcement Order, your application will be refused and you will be notified in
writing by the Infringements Court. You should either pay the amount due or lodge an objection within the time
specified on that notice. If you lodge an objection within time, the matter will be referred to the Court for a
Magistrate or a Judicial Registrar to consider. A hearing notice will be posted to you and you will be expected to
attend the Magistrates Court hearing or have a legal representative appear on your behalf.
OPTION 4:

If you suffer from one or more of the following conditions you may be eligible to have your
Enforcement Order(s) revoked under Special Circumstances (Form B):
Special Circumstances in relation to a person means a mental or intellectual disability, disorder,
disease or illness, or a serious addiction to drugs, or alcohol or a volatile substance and / or
homelessness.
Where one or more of these conditions exist you may be eligible to have your Enforcement Order(s) revoked. To
apply you must complete Form B and supply evidence by way of a recent report written by a qualified psychiatrist,
medical practitioner or health professional. Applications under Special Circumstances can be completed and signed
by a person other than the person named in the Enforcement Order, referred to as a Third Party. The Third Party
must complete all the information in Form B and attach any relevant information (eg medical, psychiatric reports or
other supporting documentation) that may assist the Infringements Registrar in determining the application.

OPTION 5:

If you did not receive the initial Infringement Notice you may be eligible for an Extension of Time:
If you were not personally served with an Infringement Notice and you were not in fact aware that it had been
issued, you may apply for an Extension of Time to act on the Infringement Notice. Under the Infringements Act 2006
and the Road Safety Act 1986, you must apply within 14 days of becoming aware of the Infringement Notice. If the
offence involves alcohol or other drug related infringements under the Marine Act 1988 or Transport Act 1983 you
must apply within 7 days of becoming aware of the Infringement Notice. If applying under the Infringements Act
2006 you must complete FORM B of the application by placing a tick in the Extension of Time box, then complete the
remainder of Form B. If applying under any of the other above mentioned Acts, contact the Infringements Registrar
immediately on (03) 9200 8222 as you must apply on a separate form (a statutory declaration) provided by the
Infringements Court. If eligible, the Registrar will refer your application for hearing before a Magistrate or Judicial
Registrar. You will be notified of the hearing date and will be required to attend.

...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
Please note: If you would like to add any further comments please attach and sign a separate sheet of paper.

WARNING:
Section 167 of the Infringements Act 2006 states that a person must not intentionally provide false or misleading information in
any written statement required by or under the Infringements Act 2006.
PENALTY: 10 PENALTY UNITS

APPLICANTS SIGNATURE:

DATE:
......../ ......../ 20........

POST TO: The Infringements Registrar, Infringements Court, PO BOX 14487, MELBOURNE VIC 8001.
If you do not understand this form, you may seek advice from:

The Infringements Registrar of the Infringements Court

Legal Representative

Victoria Legal Aid

07/06

REVOCATION GUIDE
Complete FORM A:
Complete FORM B:

APPLICATION FOR REVOCATION

Form A

To nominate a driver/owner of the vehicle


For Special Circumstances, Extension of Time and Other circumstances

1
I, (full name): ............................................................................... Date of Birth: ..........................
(PLEASE PRINT)

THE FOLLOWING ARE COMMON SCENARIOS, WHICH MAY APPLY TO YOU:


1.

of (residential address): ..................................................................................................................

Infringement Notice Not Received (Extension of Time):


If an Enforcement Order for an Infringement Notice has been made and you were not aware that it had been issued, you may be
eligible to apply for an extension of time to respond to the Infringement Notice. If you seek to make this application, tick the
Extension of Time box and complete the application. The Infringements Registrar will advise you of a Court hearing date
before a Magistrate or a Judicial Registrar which you shall be required to attend. If not eligible, your application will be
considered as an Application for Revocation.

Postcode: ................................... Contact Phone Number: .............................................................

INFRINGEMENTS
REGISTRAR
USE ONLY

Company Name*: ...........................................................................................................................


* (Complete if Enforcement Order is in the name of a company)

Company Address: .......................................................................................................................... Postcode: .............................


(Provide company address where documents can be served)

3.

Drink/Drug Driving or Excessive Speed Infringements:


ALL drink/drug driving offences and speeds of 25km/h or more over any posted limit (or in excess of 130km/h) are not eligible
for revocation. Should you wish to dispute an Order in this category, you will need to apply under different provisions of the law.
Contact the Infringements Registrar immediately on (03) 9200 8222 for further advice in relation to applications specific for this
category.

4.

CityLink Infringements:
If you had a valid e-tag, day pass or received an invoice at the time of the offence, please include a copy of your CityLink
account, day pass or paid invoice for the relevant offence date(s).

5.

If you believe that you have already paid the fine:


You should:

Check that the infringement number on your receipt is the same as on the fine

Confirm if your cheque/money order has been presented and by which agency

Check the date payment was made as late payments include additional costs.
If a cheque/money order has been presented, contact the agency directly. It may be that they were unable to allocate your
payment due to insufficient details. If the matter is unable to be resolved with the agency, then your application should include
all attempts to resolve the matter and copies of any proof of payment.

7.

8.

I am the person named in the Enforcement Order (or if a company, a person authorised by the company to make this application) in
the following Infringements Court Case Number(s):

Nominating Drivers:
Your application must include the full name, current address, licence number, and if known, date of birth of the nominated driver
or new owner. If you do not have these particulars, you must include a statement as to why you cannot fully nominate and the
efforts you have made to locate them.
An individual or a company cannot name a company as the driver of a motor vehicle in relation to the commission of an offence.
An individual must be nominated in these circumstances. An individual or a company can nominate a company as the owner of
a vehicle where the individual or the company was not the registered owner of the vehicle at the time of the offence.

6.

In the above company I hold the position of: ..................................................................................................................................

............................................................
..............................................................
and I hereby apply to have the Order(s) revoked.

WHY SHOULD THE ENFORCEMENT ORDER BE REVOKED?

I WAS NOT THE DRIVER

I WAS NOT THE OWNER

On the date of the offence I was the registered owner of the


vehicle but I was not the person who committed the offence.

On the date of the offence I was not the registered owner of the
vehicle and I was not the person who committed the offence.

On the date of the offence the vehicle was driven by:

Registration Number: .............................................................

Name: ..................................................................................
(PLEASE PRINT)

Address: ...............................................................................

Date vehicle sold: ..................................................................

OR Sold to: ................................................................................


(PLEASE PRINT)

Address: ...............................................................................
.............................................................................................

.............................................................................................

D.O.B: ....../....../........ Licence No.: .......................................

D.O.B: ....../....../........ Licence No.: .........................................

(Refer to attached Revocation Guide - Nominating Drivers)

(Refer to attached Revocation Guide - Nominating Drivers)

Parking Permits:
If your application states you had a valid parking permit (council or disability) to park in an area, a copy of the permit must be
attached. Please check the conditions of the permit to see if they apply.

Companies:
To apply on behalf of a company, you must be a person authorised by the company to make the application.

Did you receive the Penalty Reminder Notice? YES

Overseas/Interstate:
If your application states that you had been overseas or interstate, please provide evidence of the relevant dates (eg copies of
passport entries, airline tickets, boarding passes).

.............................................................

Complete ONE box only, if the offence involves a vehicle and you are stating that
you were NOT the DRIVER or NOT the OWNER of the vehicle - then proceed to section 3.

Detach and Return this page

2.

By now the Enforcement Agency (eg Municipal Council or Police) that issued the original Infringement Notice will have sent
you a Penalty Reminder Notice. (You MUST tick one box & answer the question below)
or NO

If YES, what action did you take upon receipt of this notice? .......................................................................................
.................................................................................................................................................................................
If NO, what explanation can you give for not receiving it? ...........................................................................................
.................................................................................................................................................................................

CHECKLIST
STOP

Only the person named on the Enforcement Order can complete this application unless applying under Special
Circumstances whereby a Third Party can apply on a persons behalf.
Fill in your full name and current residential address.
Provide the Infringements Court Case Number(s) and complete all relevant sections of the application.
Attach supporting documentation (ie copy of medical reports, police statements, mechanics invoice, passports).
When complete, sign your name and date the form in the area provided.

When did you first become aware of this offence? ........./........./ 20.........
4

WARNING:
Section 167 of the Infringements Act 2006 states that a person must not intentionally provide false or misleading information in
any written statement required by or under the Infringements Act 2006.
PENALTY: 10 PENALTY UNITS

APPLICANTS SIGNATURE:

DATE:
......../ ......../ 20........

REVOCATION GUIDE
Complete FORM A:
Complete FORM B:

APPLICATION FOR REVOCATION

Form A

To nominate a driver/owner of the vehicle


For Special Circumstances, Extension of Time and Other circumstances

1
I, (full name): ............................................................................... Date of Birth: ..........................
(PLEASE PRINT)

THE FOLLOWING ARE COMMON SCENARIOS, WHICH MAY APPLY TO YOU:


1.

of (residential address): ..................................................................................................................

Infringement Notice Not Received (Extension of Time):


If an Enforcement Order for an Infringement Notice has been made and you were not aware that it had been issued, you may be
eligible to apply for an extension of time to respond to the Infringement Notice. If you seek to make this application, tick the
Extension of Time box and complete the application. The Infringements Registrar will advise you of a Court hearing date
before a Magistrate or a Judicial Registrar which you shall be required to attend. If not eligible, your application will be
considered as an Application for Revocation.

Postcode: ................................... Contact Phone Number: .............................................................

INFRINGEMENTS
REGISTRAR
USE ONLY

Company Name*: ...........................................................................................................................


* (Complete if Enforcement Order is in the name of a company)

Company Address: .......................................................................................................................... Postcode: .............................


(Provide company address where documents can be served)

3.

Drink/Drug Driving or Excessive Speed Infringements:


ALL drink/drug driving offences and speeds of 25km/h or more over any posted limit (or in excess of 130km/h) are not eligible
for revocation. Should you wish to dispute an Order in this category, you will need to apply under different provisions of the law.
Contact the Infringements Registrar immediately on (03) 9200 8222 for further advice in relation to applications specific for this
category.

4.

CityLink Infringements:
If you had a valid e-tag, day pass or received an invoice at the time of the offence, please include a copy of your CityLink
account, day pass or paid invoice for the relevant offence date(s).

5.

If you believe that you have already paid the fine:


You should:

Check that the infringement number on your receipt is the same as on the fine

Confirm if your cheque/money order has been presented and by which agency

Check the date payment was made as late payments include additional costs.
If a cheque/money order has been presented, contact the agency directly. It may be that they were unable to allocate your
payment due to insufficient details. If the matter is unable to be resolved with the agency, then your application should include
all attempts to resolve the matter and copies of any proof of payment.

7.

8.

I am the person named in the Enforcement Order (or if a company, a person authorised by the company to make this application) in
the following Infringements Court Case Number(s):

Nominating Drivers:
Your application must include the full name, current address, licence number, and if known, date of birth of the nominated driver
or new owner. If you do not have these particulars, you must include a statement as to why you cannot fully nominate and the
efforts you have made to locate them.
An individual or a company cannot name a company as the driver of a motor vehicle in relation to the commission of an offence.
An individual must be nominated in these circumstances. An individual or a company can nominate a company as the owner of
a vehicle where the individual or the company was not the registered owner of the vehicle at the time of the offence.

6.

In the above company I hold the position of: ..................................................................................................................................

............................................................
..............................................................
and I hereby apply to have the Order(s) revoked.

WHY SHOULD THE ENFORCEMENT ORDER BE REVOKED?

I WAS NOT THE DRIVER

I WAS NOT THE OWNER

On the date of the offence I was the registered owner of the


vehicle but I was not the person who committed the offence.

On the date of the offence I was not the registered owner of the
vehicle and I was not the person who committed the offence.

On the date of the offence the vehicle was driven by:

Registration Number: .............................................................

Name: ..................................................................................
(PLEASE PRINT)

Address: ...............................................................................

Date vehicle sold: ..................................................................

OR Sold to: ................................................................................


(PLEASE PRINT)

Address: ...............................................................................
.............................................................................................

.............................................................................................

D.O.B: ....../....../........ Licence No.: .......................................

D.O.B: ....../....../........ Licence No.: .........................................

(Refer to attached Revocation Guide - Nominating Drivers)

(Refer to attached Revocation Guide - Nominating Drivers)

Parking Permits:
If your application states you had a valid parking permit (council or disability) to park in an area, a copy of the permit must be
attached. Please check the conditions of the permit to see if they apply.

Companies:
To apply on behalf of a company, you must be a person authorised by the company to make the application.

Did you receive the Penalty Reminder Notice? YES

Overseas/Interstate:
If your application states that you had been overseas or interstate, please provide evidence of the relevant dates (eg copies of
passport entries, airline tickets, boarding passes).

.............................................................

Complete ONE box only, if the offence involves a vehicle and you are stating that
you were NOT the DRIVER or NOT the OWNER of the vehicle - then proceed to section 3.

Detach and Return this page

2.

By now the Enforcement Agency (eg Municipal Council or Police) that issued the original Infringement Notice will have sent
you a Penalty Reminder Notice. (You MUST tick one box & answer the question below)
or NO

If YES, what action did you take upon receipt of this notice? .......................................................................................
.................................................................................................................................................................................
If NO, what explanation can you give for not receiving it? ...........................................................................................
.................................................................................................................................................................................

CHECKLIST
STOP

Only the person named on the Enforcement Order can complete this application unless applying under Special
Circumstances whereby a Third Party can apply on a persons behalf.
Fill in your full name and current residential address.
Provide the Infringements Court Case Number(s) and complete all relevant sections of the application.
Attach supporting documentation (ie copy of medical reports, police statements, mechanics invoice, passports).
When complete, sign your name and date the form in the area provided.

When did you first become aware of this offence? ........./........./ 20.........
4

WARNING:
Section 167 of the Infringements Act 2006 states that a person must not intentionally provide false or misleading information in
any written statement required by or under the Infringements Act 2006.
PENALTY: 10 PENALTY UNITS

APPLICANTS SIGNATURE:

DATE:
......../ ......../ 20........

APPLICATION FOR REVOCATION,


SPECIAL CIRCUMSTANCES AND OTHER

Form B

INFORMATION
What happens if you ignore the Enforcement Order?

If you live in Victoria, an infringement warrant will be issued to the Sheriff to seize and sell your goods or to imprison you, additional
costs will be incurred.

I, (full name): ............................................................................... Date of Birth: ..........................


(PLEASE PRINT)

of (residential address): ..................................................................................................................

INFRINGEMENTS
REGISTRAR
USE ONLY

WARNING:

Postcode: ................................... Contact Phone Number: .............................................................


Third Party (full name)*: ...............................................................................................................................................................

If you do not pay the infringement penalty and prescribed costs or take one of the courses of action
outlined below, enforcement action will be taken against you. This action may include:

the issue of an infringement warrant authorising the seizure of your personal property

your driver licence or motor vehicle registration may be suspended and/or not renewed, and/or
not transferred

your motor vehicle may be immobilised (eg by wheel clamping), seized and sold

you may be subject to an attachment of earnings or an attachment of debts order

your real estate may be subject to a charge order and sale

you may be arrested pursuant to the Infringements Act 2006 and brought before the Court

*(If completing application on behalf of someone who has Special Circumstances provide your full name)

of (residential / business address): ................................................................................................... Postcode: .............................

OPTION 1:

Pay the amount due:


For payment details, please refer to your Enforcement Order Notice or contact the following numbers:
Melbourne:
(03) 9200 8222
Country Victoria Only:
1800 150 410

OPTION 2:

Ask for extra time to pay the amount:


Phone the Infringements Court during business hours on (03) 9200 8222, before the amount is due, to apply
for additional time to pay the fine, or to pay the fine by instalments.

OPTION 3:

Apply for Revocation of the Enforcement Order (ie for the Order to be cancelled and the case to be
heard in court):
If you believe you are not guilty of the offence or had a valid reason for committing the offence, you can apply to
have this order revoked. More information on revocations is available on (03) 9200 8222.

Relationship of Third Party**: ........................................................................................................................................................


**(Relationship of Third Party to person named in Enforcement Order eg Carer, Parent, Spouse, Treating Doctor, Psychologist)

Company Name***: ......................................................................................................................................................................


*** (Complete if Enforcement Order is in the name of a company)

Company Address: .......................................................................................................................... Postcode: .............................


(Provide company address where documents can be served)

In the above company I hold the position of: ..................................................................................................................................

............................................................
..............................................................
and I hereby apply to have the Order(s) revoked.

.............................................................

WHY SHOULD THE ENFORCEMENT ORDER BE REVOKED?


2
Please tick the appropriate box relevant to your application to have the Enforcement Order revoked:
SPECIAL CIRCUMSTANCES EXIST (READ OPTION 4)
EXTENSION OF TIME (READ OPTION 5)*
*(NOTE: This is not an extension of time to pay the Enforcement Order amount please refer to OPTION 2)
OTHER

Please provide details below:


I first became aware of this offence on ....../....../ 20......

Detach and Return this page

I am the person named in the Enforcement Order (or if a third party, a person authorised to apply on behalf of the person named in
the Enforcement Order, or company, a person authorised by the company to make this application) in the following Infringements
Court Case Number(s):

To apply for revocation you must fill in the attached written statement and return the form to the
Infringements Court by the due date for payment.
If you are stating that you were neither the driver nor the owner of the vehicle at the time the
offence was committed, you must complete Form A of the application.
If you did not receive the Infringement Notice, or are applying under Special Circumstances, or have
a other valid reason, you must complete Form B of the application.
What happens if I apply to have the Court Order revoked?
The Infringements Registrar of the Infringements Court will consider your application and if there are sufficient
grounds to justify revocation, the Enforcement Order will be revoked. The matter of the infringement offence will
then be referred back to the Enforcement Agency that issued the infringement (eg Police, Municipal Council) for
their consideration. They may decide to not proceed with the Infringement Notice or have it referred to a
Magistrates' Court for hearing in which case a hearing notice will be posted to you. You will be expected to
attend the Magistrates' Court hearing or have a legal representative appear on your behalf.
If the Order has been revoked due to a nomination being supplied, the Infringements Court may cancel the
Infringement Notice and the Enforcement Agency will be notified. If the Infringements Registrar decides that there
are insufficient grounds to cancel the Enforcement Order, your application will be refused and you will be notified in
writing by the Infringements Court. You should either pay the amount due or lodge an objection within the time
specified on that notice. If you lodge an objection within time, the matter will be referred to the Court for a
Magistrate or a Judicial Registrar to consider. A hearing notice will be posted to you and you will be expected to
attend the Magistrates Court hearing or have a legal representative appear on your behalf.
OPTION 4:

If you suffer from one or more of the following conditions you may be eligible to have your
Enforcement Order(s) revoked under Special Circumstances (Form B):
Special Circumstances in relation to a person means a mental or intellectual disability, disorder,
disease or illness, or a serious addiction to drugs, or alcohol or a volatile substance and / or
homelessness.
Where one or more of these conditions exist you may be eligible to have your Enforcement Order(s) revoked. To
apply you must complete Form B and supply evidence by way of a recent report written by a qualified psychiatrist,
medical practitioner or health professional. Applications under Special Circumstances can be completed and signed
by a person other than the person named in the Enforcement Order, referred to as a Third Party. The Third Party
must complete all the information in Form B and attach any relevant information (eg medical, psychiatric reports or
other supporting documentation) that may assist the Infringements Registrar in determining the application.

OPTION 5:

If you did not receive the initial Infringement Notice you may be eligible for an Extension of Time:
If you were not personally served with an Infringement Notice and you were not in fact aware that it had been
issued, you may apply for an Extension of Time to act on the Infringement Notice. Under the Infringements Act 2006
and the Road Safety Act 1986, you must apply within 14 days of becoming aware of the Infringement Notice. If the
offence involves alcohol or other drug related infringements under the Marine Act 1988 or Transport Act 1983 you
must apply within 7 days of becoming aware of the Infringement Notice. If applying under the Infringements Act
2006 you must complete FORM B of the application by placing a tick in the Extension of Time box, then complete the
remainder of Form B. If applying under any of the other above mentioned Acts, contact the Infringements Registrar
immediately on (03) 9200 8222 as you must apply on a separate form (a statutory declaration) provided by the
Infringements Court. If eligible, the Registrar will refer your application for hearing before a Magistrate or Judicial
Registrar. You will be notified of the hearing date and will be required to attend.

...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
Please note: If you would like to add any further comments please attach and sign a separate sheet of paper.

WARNING:
Section 167 of the Infringements Act 2006 states that a person must not intentionally provide false or misleading information in
any written statement required by or under the Infringements Act 2006.
PENALTY: 10 PENALTY UNITS

APPLICANTS SIGNATURE:

DATE:
......../ ......../ 20........

POST TO: The Infringements Registrar, Infringements Court, PO BOX 14487, MELBOURNE VIC 8001.
If you do not understand this form, you may seek advice from:

The Infringements Registrar of the Infringements Court

Legal Representative

Victoria Legal Aid

07/06