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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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.
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
Current address. 3999 Example Street
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 thisfee 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.
I have read and completed this form and all details are true and correct.
Signature C. Bostock
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.
The State Debt Recovery Office (SDRO) can arrange to have your fortnightly instalment payments deducted from your eligible Centrelink Benefit using the Centrepay program:
I authorise SDRO to advise Centrelink:
I give permission for Centrelink to pay the amounts directly to SDRO. I understand that:
Your personal information is protected by law. Centrelink may give your information to SDRO for the purposes of:
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.