This is a text only version of a Sample Payment by Instalments - Companies. It is not legal advice.
To see what a completed form could look like, see the pdf version of
Sample Payment by Instalments - Companies (238kb).
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Payment by Instalments - Companies
To apply to pay your fine by instalments.
Company name. HA Packaging Pty Ltd
Best contact no. 9999 8888
Mailing address. 1/141 Sample Road
Trading address As above
Overdue Fine No. 123456789
Is the company currently trading? Yes No
Name of company Bank/Credit Union. Eastpac Bank
Do you own vehicles? Yes No
Rego no(s) ABC 123 and XYZ 789
How much can the company afford to pay per fortnight? $ 40.00
The information contained is true and correct and I am authorised by the company to complete this document.
Name Harry Anderson
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
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State of New South Wales through the Office of State Revenue, 2015. 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 043 | Payment by Instalments - Companies | December 2015