This is a text only version of a Sample Court Election Form - Companies. It is not legal advice.
To see what a completed form could look like, see the pdf version of
Sample Court Election Form - Companies (137 kb).
If you need more help, call
Enquiries 1300 655 805
TTY 133 677 Speak and Listen 1300 555 727 Email us via:
To have your penalty notice decided in court
I elect to have Penalty Notice No. 1010101010 determined by a court.
I understand the Company named on the penalty notice will receive a Court Attendance Notice (CAN) and a representative will have to go to court.
Company name HA Packaging Pty Ltd
Full name of person completing court election form Harry Anderson
Position (duly authorised to sign on behalf of the company) Director
I elect to receive the company CAN by Email (Note: If the email box is not selected the CAN will be sent by post.)
Company address 1/141 Sample Road
Best contact no. 9999 8888
Signature H. Anderson
Information collected from you for the purpose stated on this form may be provided to third parties with your consent or as required or permitted by law. OSR will correct or update your personal information at your request. Read more about privacy at
Office of State Revenue: ISO 9001 - Quality Certified | Department of Finance & Services
State of New South Wales through the Office of State Revenue, 2013. This work may be freely reproduced and distributed for most purposes, however some restrictions apply. Read the copyright notice at
www.osr.nsw.gov.au or contact OSR.