Sample early enforcement to pay by instalments - penalty notices (Centrelink customers only)

This is a text only version of a sample early enforcement to pay by instalments - penalty notices (Centrelink customers only) form. It is not legal advice.

To see what a completed form could look like, see the pdf version of Sample early enforcement to pay by instalments - penalty notices (Centrelink customers only) (165 kb).

If you need more help, call LawAccess NSW.

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Email us via: http://www.revenue.nsw.gov.au/contact
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Early Enforcement to Pay by Instalments - Penalty Notices (Centrelink Customers Only)

To apply to pay your penalty notice by instalments when you receive a Centrelink benefit.

Note:

• Print clearly using BLOCK LETTERS in the space provided and tick the appropriate boxes
• If all sections are not completed, your application cannot be processed
• If you receive a government benefit, you can save the $65 enforcement fee by completing this form to set up an instalment plan on Centrepay before the due date on the reminder notice. If the due date is near or you don't
  wish to use Centrepay, please phone us. You should not set up instalments if you wish to dispute or seek leniency for the fine. By choosing early enforcement you are accepting liability and waiving your rights to dispute.
• Please send your completed form to State Debt Recovery Office, PO Box 786, Strawberry Hills NSW 2012; or scan and email us via http://www.revenue.nsw.gov.au/contact

Your details

Title Mr Mrs Miss Ms Other

First name. Charlie

Last name. Bostock

Date of birth. 10/12/1977

Best contact no. 0499666111

Licence no. 1006FR

Email. cbostock@pmail.com

Current address. 3999 Example Street

Suburb Ashfield

State NSW

Postcode 2131

Postal address (if different) As above

Suburb State Postcode

Note: Please select preferred contact address: Email Current Postal

I wish to pay the following penalty notices by instalment:1010101010

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
fee and any other enforcement costs.

I can afford to pay $ 15.00 per fortnight (minimum $15 a fortnight)

Centrelink Reference Number (CRN) 555 123 456 7

Benefit type Newstart Allowance

Please arrange Centrepay deductions. I have read the deduction authorisation on the back of this form.

Declaration

I have read and completed this form and all details are true and correct.

Signature C. Bostock

Date

20/03/2014

Note: Any information provided may be used by SDRO or provided to third parties with your consent as or required or permitted by law.

Important: See over the page for more information.

If you also have enforcement orders which you wish to pay by instalment, please list them here.

Centrepay information

The State Debt Recovery Office (SDRO) can arrange to have your fortnightly instalment payments deducted from your eligible Centrelink Benefit using the Centrepay program:

• All Centrelink payments are eligible for the Centrepay Program. Centrepay deductions are voluntary.
• Deductions will automatically cease when your instalment arrangement is paid in full.
• If your Centrelink payments are cancelled and/or you stop making payments via Centrepay, you are still required to make your agreed repayments to avoid further enforcement action.
• You must contact SDRO to add new enforcement orders to your payment arrangement. We will then reassess your repayment amounts and advise Centrelink of any changes.
• You can make changes to your Centrepay deductions by contacting SDRO or Centrelink.
• If you wish to set up Centrepay deductions for your fortnightly instalment payments, read the deduction authorisation and sign the declaration.

Deduction authorisation

I authorise SDRO to advise Centrelink:

• to make the nominated deduction each fortnight from my current Centrelink payment(s) in respect of my agreement with SDRO
• to vary the deduction or target amount or suspend the nominated deduction from time to time to ensure my obligations under my
  arrangement to pay by instalments are met
• of my correct account or billing number if required.

I give permission for Centrelink to pay the amounts directly to SDRO. I understand that:

• it is my choice to have amounts deducted from my Centrelink payment and that I can change or cancel the deduction at any time
  by contacting SDRO or Centrelink
• if I transfer to another eligible Centrelink payment in the future that my current deductions will continue
• if I stop using SDRO services but do not stop my Centrepay deduction, SDRO may instruct Centrelink to stop the deduction
• Centrelink will notify me in a letter of any changes to my deduction details, including changes requested by SDRO
• if deductions from my Centrelink benefits are cancelled for any reason, I am still required to make the agreed repayments on my
  arrangement to pay by instalments
• my consent will be noted on my account record with SDRO.

Privacy statement

Your personal information is protected by law. Centrelink may give your information to SDRO for the purposes of:

• checking your account number and the amount you want to pay
• reconciling your payment deduction details.
  SDRO may give your personal information to Centrelink for the purposes of:
• establishing a Centrepay arrangement to make payments by instalments
• setting a target amount, equal to your current instalment arrangement, for the Centrepay deductions
• updating deduction or target amounts as required

You may correct or update your personal information by contacting SDRO.

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State of New South Wales through the Office of State Revenue, 2012. 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.