Sample Declaration of your circumstances
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.
For more information about completing this form, see Instructions for completing the Declaration of your circumstances.
Case study – Sofia Kelly
Sofia Kelly has received an overdue fine from Revenue NSW for a restitution debt. She is a single mother, unemployed and a full-time carer for her elderly mother who is quadriplegic and also suffers from dementia. Sofia has recently been diagnosed with acute bipolar depression and is on medication. She is receiving Centrelink benefits and has no assets of value. Sofia contacted an advocate and was advised that a WDO is not suitable. She wants to apply for a write off.