​ሕግንና ደንብን በተመለከተ እርዳታ ማግኘት ይፈልጋሉን? - Amharic | هل تحتاج لمساعدة قانونية؟ - Arabic | ܤܢܝܼܩܵܐ ܝ݇ܘ̤ܬ ܠܗܲܝܵܪܬܵܐ ܩܵܢܘܿܢܵܝܬܵܐ؟ - Assyrian | Need Legal Help? - Auslan | Treba li vam pravna pomoc? - Bosnian | Burmese â Need Legal Help? | 需要法律帮助吗? - Chinese Simplified | 需要法律幫助嗎? - Chinese Traditional | Trebate li pravnu pomoć? - Croatian | ضرورت به کمک قانونی دارید؟ - Dari | Wïc Kuɔɔny në Wɛ̈t Löŋ? - Dinka | آیا به کمک حقوقی نیاز دارید؟ - Farsi | Gadreva na Veivuke Vakalawa? - Fijian | Kailangan ninyo ba ng tulong na panglegal? - Filipino | Besoin d’aide juridique ? - French | Χρειάζεστε βοήθεια σε νομικά ζητήματα - Greek | क्या आपको कानूनी सलाह चाहिए? - Hindi | Butuhkan Bantuan dalam Masalah Hukum? - Indonesian | Hai bisogno di assistenza legale? - Italian | ត្រូវការជំនួយលើបញ្ហាផ្លូវច្បាប់ឬទេ? - Khmer | 법적인 도움이 필요하십니까? - Korean | Ви треба ли помош со правни работи? - Macedonian | कानूनी सहयोग चाहिएको छ? - Nepalese | Necessita de ajuda com questões jurídicas? - Portuguese | Вам нужна юридическая помощь? - Russian | E Manaomia Fesoasoani i Mea Tau Tulafono? - Samoan | а ли вам треба помоћ у правним питањима? - Serbian | Ma u baahan tahay Caawimmad xagga sharciga ah?- Somali | ¿Necesita ayuda con cuestiones jurídicas? - Spanish | சட்ட உதவி தேவையா? - Tamil | ท่านต้องการความช่วยเหลือทางด้านกฎหมายไหม? - Thai | Fiema’u ha tokoni Fakalao? - Tongan | Yasal Danışmaya İhtiyacınız mı var? - Turkish | Cần Được Giúp Đỡ Về Luật Pháp? - Vietnamese |

​Sample Court Election Form - Individuals ​

Form Assistance Icon​​This is a text only version of a Sample Court Election Form - Individuals. It is not le​gal advice.

To see what a completed form could look like, see the pdf version of Sample Court Election Form - Individuals ​PDF icon (158 kb)

If you need more help, call LawAccess NSW.


Enquiries 1300 138 118​​
TTY 133 677  Speak and Listen 1300 555 727

Email us via: http://www.revenue.nsw.gov.au/fines/pn/court


Court Election Form - Individuals

To have your penalty notice decided in court

Note:

  • You may wish to request a review before going to court, if you have not already. If the outcome is not in your favour, you will have a further 28 days to advise us if you want to have the penalty decided in court
  • If you want us to conduct a review, do not submit this request to have the penalty decided in court. By law, we must stop any review which may be in progress when we receive a request to go to court
  • Print clearly using BLOCK LETTERS in the space provided
  • If all sections are not completed, your application cannot be processed
  • Provide a street address for service of the Court Attendance Notice (CAN). A CAN cannot be served to a PO Box address
  • Do not pay your fine before lodging this form
  • Court may impose additional costs
  • Please send your completed form to State Debt Recovery Office, PO Box 786, Strawberry Hills NSW 2012

I elect to have Penalty Notice No. 1010101010 determined by a court.
I understand I will then receive a Court Attendance Notice (CAN) and have to go to court.

Given name(s) Charlie

Surname Bostock

Licence number 1006FR

State of issue NSW

Date of birth 10 12 1977

Best contact no. 0499666111

I elect to receive my CAN by Email   (Note: If the email box is not selected the CAN will be sent by post.)

Email cbostock@pmail.com

Street number and street address 3999 Example Street

Suburb Ashfield

State NSW

Postcode 2131

Country Australia

Signature C. Bostock

Date  20/03/2014

Privacy statement

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 www.osr.nsw.gov.au

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.

SDR 020  | Court Election Form - Individuals | November 2013