This is a text only version of a Sample Request for Review of a Penalty Notice. It is not legal advice.
To see what a completed form could look like, see the pdf version of
Sample Request for Review of a Penalty Notice (340 kb).
If you need more help, call
Enquiries 1300 138 118
TTY 133 677 Speak and Listen 1300 555 727
See over the page for full State Debt Recovery Office contact details.
Request for Review of a Penalty Notice
Penalty Notice No. 1234567890
Date of offence 17/11/2013
Personal details Mr Mrs Miss Ms Other
Family name Lack
Given name Laura
Postal address 17 Sample Road
Suburb. Lilyfied State. NSW Postcode. 2040
Licence no. 12345678
State of issue NSW
Date of birth 05 04 1972
Best contact no. 0444444444
Best time to contact business hours
Note: Please select preferred contact address: Postal Email
To review a penalty notice, we need the authority of the vehicle owner if you are not the person named on the penalty notice or the registered owner of the vehicle. The 'Authority to Act' form is available at http://www.revenue.nsw.gov.au, or by contacting us.
Refer to SDRO Review Guidelines for details of circumstances we can review and evidence required.
Reason for your request:
I left my vehicle for the purpose of obtaining change. I returned with the change, and I confirmed this with the issuing officer (SDR Review Guidelines 1.11).
I intended to pay for the parking but I only had a $10.00 note and the meter would only take coins. I walked to a cafe close to where I had parked and got some change. When I returned, the Ranger was putting a fine on my windscreen. I tried to explain what had happened but he left the fine and walked away.
Attached documentary evidence is:
Important: See over the page for more information.
How to Request for Review of a Penalty Notice
Important information you need to know
Do NOT use this form if:
What evidence do I need to supply to support my request?
For full details of what evidence to supply in support of your claim, refer to the SDRO Review Guidelines.
Some examples include:
State Debt Recovery Office contact details
Phone: 1300 138 1188:00 am - 5:30 pm, Mon. to Fri.Fax: (02) 4937 9111
Hearing or speech impaired users:TTY 133 677Speak and Listen 1300 555 727
Interpreter services:Phone: 131 450
Postal correspondence only:State Debt Recovery OfficePO Box 786Strawberry Hills NSW 2012
Email us via:http://www.revenue.nsw.gov.au/contact
Mail payments only:State Debt Recovery OfficePO Box 4444Parramatta NSW 2124
Refer to your penalty notice for other payment options.
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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.