This is a text only version of a Sample Payment by Instalments - Individuals. It is not legal advice.
To see what a completed form could look like, see the pdf version of
Sample Payment by Instalments - Individuals (270 kb).
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Payment by Instalments - Individuals
To apply to pay your overdue fine(s) by instalments (or penalty notice(s) if you receive a government benefit).
First name. Laura
Last name. Lack
Date of birth. 05 04 1972
Best contact no. 0444444444
Licence no. 12345678
Vehicle rego. ABC 123
Current address. 17 Sample Road
Postal address (if different) As above
Note: Please select preferred contact address:
I wish to pay the following by instalments:Overdue Fine Number(s) 123 456 789
Penalty Notice Number(s)
(must be on a government benefit - must sign declaration on next page)
I can afford to pay $30.00 per fortnightCentrelink Reference Number (CRN)
ABN (if applicable)
Employer business name AA Packaging Pty Ltd
Employer phone no.(02) 9999 8888
Please arrange Centrepay deductions. I have signed the deduction authorisation on the back of this form.
Name of your Bank/Credit Union. Eastpac Bank
DeclarationI have read and completed this form and all details are true and correct.
Signature L. Lack
Note: Any information provided may be used by State Debt Recovery or provided to third parties with your consent as or required or permitted by law.
Important: See over the page for more information.
For penalty notices only:
Where I have requested penalty notice(s) be paid by instalment, I confirm I am on a government benefit and understand that by choosing to pay my penalty notice by instalment I am accepting liability for the offence and waiving my right to seek a review or choose to go to court about the penalty notice(s) shown. I understand the enforcement fee will not be applied to my penalty but if I fail to comply with my payment plan, I will be liable for this and any other enforcement related fees.
State Debt Recovery (SDR) can arrange to have your fortnightly instalment payments deducted from your eligible Centrelink Benefit using the Centrepay program:
For the purpose of this payment plan, I authorise State Debt Recovery to advise Centrelink:
I give permission for Centrelink to pay the amounts directly to State Debt Recovery. I understand that:
I have read and completed the information on this form and request that State Debt Recovery organise Centrepay deductions on my behalf.
Your personal information is protected by law. Centrelink and State Debt Recovery may share your personal information to fulfil the obligations of your agreed payment plan.
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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 040 | Payment by Instalments - Individuals | December 2015