Embed Size (px)
Citation preview
Reference Number/s: _____________________________________________________________(eg Obligation, Case Number or Warrant Number)
Do you have an existing payment order to pay by instalments? (please tick one) NO YES
If you have ticked YES, please provide current Instalment Payment Plan Number: ______________________If you have failed to comply with a previous payment arrangement in the past, please supply reasons here:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
APPLICATION FOR PAYMENT ORDERInfringements Act 2006, section 76
APPLICATION: (please tick one) TO PAY BY INSTALMENTS OR FOR ADDITIONAL TIME TO PAY
I hereby make application for a payment order to pay by instalments/for additional time to pay pursuant to section 76 of theInfringements Act 2006 and state that the following information is true and correct
IF THE COURT IDENTIFIES FURTHER UNPAID FINES IN YOUR NAME, IT IS ASSUMED THAT YOURAPPLICATION ALSO APPLIES TO THOSE MATTERS
APPLICANT’S DETAILS (please print in capital letters)
Full Name: ____________________________________________________ Date of Birth: ___ / ___ / _______Previous Names: ________________________________________________ Driver Licence Number: _________(eg Maiden name)
Residential Address: ______________________________________________________ Postcode: ___________Postal Address: __________________________________________________________ Postcode: ___________Previous Addresses: __________________________________________________________________________Phone (Home): _____________________ (Work): _____________________ (Mobile): ____________________All Vehicle Registration Numbers: _______________________________________________________________
EMPLOYMENT/INCOME DETAILS Occupation: ______________________________________________________________________________Employer: ______________________________________________________________________________
(including address)
Net Wages: $_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(fortnightly)
Other Income: $_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(eg rental income, investments)
BENEFIT DETAILSBenefit/Pension type: ______________________________________________________________________
(eg Newstart)
Benefit/Pension Number: ______________________________________________________________________(eg Centrelink Customer Reference Number (CRN))
Amount received fortnightly: $_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
FORTNIGHTLY EXPENSESRent/Mortgage/Board: (please circle) $ ___________ Other Expenses: (give details)
Food: $ ___________ _______________________________ $ ______________Electricity/Gas/Telephone: $ ___________ _______________________________ $ ______________Car Expenses: $ ___________ _______________________________ $ ______________Public Transport: $ ___________ _______________________________ $ ______________Medical Expenses: $ ___________ Total Fortnightly Expenses: $ ____________
ASSETS & LIABILITIESProperty Value Amount owedHouse: $ ________________________ $ _________________________Car: $ ________________________ $ _________________________Other property: $ ________________________ $ _________________________Other debts: $ ________________________ $ _________________________(eg Credit cards, personal loans)
07/06
Please note: If you indicate that you are currently receiving benefits from Centrelink you may be able to haveinstalments directly debited from your fortnightly income.
STATE THE REASONS WHY YOU WISH TO MAKE THIS APPLICATIONPlease provide any exceptional circumstances you would like to be considered for this application and attachany supporting documentation.________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
You can apply to either extend the due date or pay by regular instalments of an agreed amount.
PAYMENT ORDER APPLICATION:
TO PAY BY INSTALMENTS
I would like to pay by instalments of $_________ every fortnight/month (please circle one)
starting on ____ /____ /____ (no more than 28 days from date of application).
OR
ADDITIONAL TIME TO PAY
I will pay the full amount due by ____ /____ /____ (not more than 3 months from the date of application).
WARNING: If your application is granted and you do not make each instalment payment by thedue date, the Court will issue a warrant for the full amount owing against each outstandingenforcement order applicable and you may incur additional costs.REMEMBER: It is your responsibility to ensure that each payment is made on or before the duedate.
Please note - Before submitting this application to the Infringements Registrar, please check toensure that all relevant sections as they apply to you have been completed.
*IMPORTANT*Penalties for making a false or misleading statement apply.If the Infringements Registrar finds a statement to be false or misleading, any existing paymentorder may be cancelled. Furthermore, a penalty of 10 penalty units applies for giving a false ormisleading statement, pursuant to section 167 of the Infringements Act 2006.
I declare that the information contained in this written statement is true and correct.
SIGN HERE ________________________________________________
Dated ____ /____ /____
The person named in the Enforcement Order MUST sign this written statement and all attached documents.
POST TO: THE INFRINGEMENTS REGISTRARINFRINGEMENTS COURT PO BOX 14487MELBOURNE VIC 8001
07/06
