Department of Justice is now the Department of Communities and Justice. Find out more >
This page links to an example of a completed form. This is the actual form with sample text added in each section.
You should make sure that your form relates to your circumstances. If you need more help to prepare your form, get legal advice.
Do not try to file this sample form.
This sample form is provided in PDF format.
Sample Authority to Act - Revenue (528KB)
For more information about completing this form, see Instructions for completing the Authority to Act - Revenue.
Sofia Kelly has received an overdue fine from Revenue NSW for a restitution debt. She wants to authorise her social worker, Kate Louis to deal with Revenue NSW on her behalf. She completes an Authority to Act form.