Department of Justice is now the Department of Communities and Justice. Find out more >
This is a text only version of a Sample Court Election Form - Individuals. It is not legal advice.
To see what a completed form could look like, see the pdf version of
Sample Court Election Form - Individuals (158 kb)
If you need more help, call
Email us via: http://www.revenue.nsw.gov.au/fines/pn/court
Court Election Form - Individuals
To have your penalty notice decided in court
I elect to have Penalty Notice No. 1010101010 determined by a court.I understand I will then receive a Court Attendance Notice (CAN) and have to go to court.
Given name(s) Charlie
Licence number 1006FR
State of issue NSW
Date of birth 10 12 1977
Best contact no. 0499666111
I elect to receive my CAN by Email (Note: If the email box is not selected the CAN will be sent by post.)
Street number and street address 3999 Example Street
Signature C. Bostock
Information collected from you for the purpose stated on this form may be provided to third parties with your consent or as required or permitted by law. OSR will correct or update your personal information at your request. Read more about privacy at
Office of State Revenue: ISO 9001 - Quality Certified | Department of Finance & Services
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.
SDR 020 | Court Election Form - Individuals | November 2013